P - 84601- , ` RE�UEST FOR ELECTRICAL �SPEJ�.,.�ION
'�� J- 8 9 5 Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-OS00
Home Duplex Apt. Bldg. Other: New Addn
Commercial Indusfrial Farm Remod Re ir
Air Cond. Htg. Equip. Water Hir. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this requesi. Enter remarks in this space and on the back of the whi�e copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance ize Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 0 Amps S'; c c'� 0 to 100 Amps
Sheet Ltg./Traffic $ig. Above 200 Am s Above 100 Amps
Tronsformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Oudine Ltg. Xfmr. ,+2 S
S C�
Alarm/Remote Conhol
Swimming Pool
i hereb certi that I ins ted the elechical insfallafion described herein on the dafes stated
Irrigation Boom � Roo9h-io pare
Special lnspecti
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Investigative Fee .�'_�____��
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validation daTe prinled in this box.
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* � 4 5 9 8 9 5 9* PLEASE PRINT OR TYPE
Request Dafe Rou h-in ins fion r uired?
g pec eq ❑ Yes o Inspection Other Than Rough-In: eady Now ❑ Will Call
�� 3"� 7 �You mvsi call the inspecfor when ready) Date Ready: ��- �
I, icensed conhactor ❑ owner hereby request inspection of the above elecfrical work at:
hb Address �Sheef, Box, or RoWe No.) City � Zip Code
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Section No. Township Name or No. Range No. Fire No. County
h o,�GC
���pa�� � Phone No.
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Power Supplier� Address
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EI 'wl Conhacfor (Company Name) � Conhacfor License No. Master Lic. No. �Plant Elec1. Only)
s��� e�T/'r � �"�tG � � pa /9�
Nlailing Addreu onhacfor or Owner PerForming Installafion)
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Authorized Sig ture �Conhaclor w Owner Performi Install fio Phone No. �
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E 1 A- 8/96 STATE BOARD COP SEE STRUCTIONS ON BACK OF YELLOW COPY