P - 84440_ �� j REGIUEST FOR ELECTRICAL INSPECTION
�II I� III II III II III II III II III II �II II ��I I I��I Minnesota State Board of Electricity ����
1E21 Unroersity Ave., Rm. S-128, St. �aul, MN 55104 :♦��
°* 0 2 9 9 3 4 0 0 �k Phone (612),642-0800
Home Duplex Apt. Bldg. Other: New Addn
mmercial Industrial Farm � � Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmi. Othe :
D er Ran e Elec. Heat Tem . Service ' U'Q'Z O� G� �
"k' obove the work covered by this request. Enter remarks in this space and on the back of the white copy only.
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Calculate Inspection Fee �This Inspection Request will not be acce fed without the correct fe •
P e.
Ofher Fee # Service Errtrance Sae Fee # Ciraits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic $ig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'susEONLY TOTAL
$ign/Outline Ltg. Xfmr. �/. ��
Alarm/Remote Contro
Swimming Pool , a / / R� / +� � �7
I hereb cerli that I ins }he elecfnc insfallofion desc�it��i�ierem n�dates �edT� - 1
Irrigdtion Boom Rough-In
Special Inspecti ��-
Investigative Fee Final
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MON HS.
2 9 9- 3 4 0� OFFlCE USE ONLY This request void 18 months from validation dafe printed in this box.
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PLEASE PRINT OR TYPE �t S� �/`�`!
Request Dat rn Rough-in inspedion required2 es � No Inspedion Other Than Rough-In: � Ready Now ill Call
'� � V �� (You musf call the inspecFOr when ready) Date Ready:
I, ❑ licensed contractor owner hereby request inspection of the above electrical work at:
Job Address (S}reef, Box, or Ro o.) �� City ��`T Zip Code
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Seclion No. Township Name or No. Range No. Fire No. C un1y
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Occuponf Phone No.
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Power $upplier Address
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Elecirical Conirador C/omlpany Name) Confractor License No. Masfer Lic. No. (Planf Elecf. Only)
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Mailing Address (Confmdo�r ner Perf�ing Installofion)
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Authorized 5' oature w P�rfb ' 'on) � ' .� Phone No.
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EB- - 0 6/95 TEBO COPY- INSTRUCTIONSONBACKOFYELLOWCOPY