P - 81933REGIUEST FOR ELECTRICAL INSPECTION
8 O���� Q � Minnesota State Board of Electricity
v 1821 University Ave., Rm. S-128, St. Paul, MN 55104 -
Phone 642-0800 "�'
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ome Duplex Apt. Bldg. Other:/�QQ C N w Addn
Commercial Industrial Farm 3� emod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" bove the work covered by this request. EPter 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 accepied withoui the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
TransFormer/Generator INSPEQTOR'S USE ONLY T A �
Sign/Outline Ltg. Xfmr. ��' �' 9 3 =��� ~ �
Alarm/Remote Control
Swimming Pool _
I here certi that I ins 1he elechica s r' herein on the dafes staled
Irrigation Boom Rough-In � Da � �`
Special Inspection '
Final Da
Investigative Fee a ��
THIS INSTALLATION MAY BE ORDERED DiSCO ED IF NOT COMPLETED WITHIN 18 MONTH .
� OFFICE USE ONLY This raquesf void 18 months from validation dafe printed in fhis box.
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PLEASE PRINT OR TYPE
Request Dafe Rough-in inspection requiredZ ❑ Yes ❑ No Inspection Other Than Rough-In: ❑ Ready Now � Will Call
(You must call the inspector when ready� Date Ready:
I, ❑ licensed contractor�owner hereby request inspection of the above electrical work at:
Job Address �Shcet, Box, or Route No.) Ci Zip Code
I�( . i+� w►�E �' d, 5�32
Seclion No. Township Name or . �plp.�y fyry No. ounty ��
l7 V V
Occupan�� �� , • �� .. PhOne No. /) ^ .
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Power Supplier �� Address
Elechical Conhacfor ICompany Name� Conkactor License No. Master Lic. No. (Plant Elecl. Only)
Maili Address � koctor rn Owner Perimming Installalion) �
�5�1 • �= v� �16 �►�i d, N- �2
Authorized S' na re �Confr r r rforming sfallafion� Phone No.
Q/h,t� . ib3 780 •
EB-0OOOlA-11 96 S BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY