P - 82955REQUEST FOR ELECTRICAL INSPECTION
6 3 f�- a 2 7 � Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
' Phone(612)642-0800
Home Duplex Apt. Bldg. Other: New Addn
ommercial Industrial Farm Remod Re
Air Cond.C3 Htg. Equip. Water Htr. Load Mgmt. Other.
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
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Calculaie Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Sfreet Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOf�T�L�Q
Sian/Oudine Lta. Xfmr. l r a�'
Alarm/Remote Control
Swimming Pool
I here cerTi fhat I ins the electrical insfallafion described herein on the dafes sfa�ed
Irriaation Boom _ oti,��., n,,,e
rmai va i— � �
Investigative Fee •
THIS INSTALLATION MAY BE ORDERED DISCONNEGTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 monfhs from validation date printed in Ihis box.
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PLEASE PRINT OR TYPE
Requesf Dafe Rou h-in ins ion r uired?
g pecY eq ❑ Yes o Inspecfion Other liian RougMn: Ready Now � Will Call .
�`fou musf mll ihe inspector when ready� Date Ready:
I, licensed confractor ❑ owner hereby request inspection of the above electrical work at:
1ob Addreu �Sheet, Box, or Route No.) � Ciy ' Zip Code
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Seclion No. Township Name or No. Range No. Fire No. C nty
Occupant
Power $upplier
hicol Conhacfor (Company Name)
$rJCVCFt ��Q.C�'JC�(,C
ling Address (Confraclor or Owner PerForming Insfal
2114 GINa�sh.ing�an S� N. e
iorized Sipnature IConh r or Owner Performina 1
11 8/96 STATE BOARD
Address
Conhador License No. Master Lic. No. (Plant E
caa1700
2 �-
. Phone No.
� 781-6200
INSTRUCTIONS ON BACK OF YELLOW COPY