P - 84556� REQUEST FOR ELECTRICAL INSPECTION
4 r J� 2 3 5 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
Commercial Indushial Farm Remod Re air
Air Cond. Htg. Equip. Water Hh. Load Mgmt. pther:
Dryer Ra�ge Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space ond on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted withou� fhe correct I�e:
Other Fee # Service Entran Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 00 Amp ,(,D 0 to 100 Amps %� GQ
Sheet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
$ign/Outline Ltg. Xfmr.
Alarm/Remote Conhol �� s
$wimming Pool
I hereb certi that I ins ted the eleclrical installafion described herein on the dates stated
Irrigation Boom Rough-In pa�
Special Ins
Final �
Investigative Fee C c__—` _� %
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months (rom validation date printed in this box.
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* 0 4 3 9� 3 5 3�Ic PLEI4SE PRINT OR TYPE
Request Date G� Rough-in inspecfion required? ❑ Yes -No Inspeclion Other Tnan RougMn: Ready Now ❑ Will Call
�'�� �j^ / 7 (You must call the inspector when ready� Date Ready:
I, �licensed confractor ❑ owner hereby request inspection of the above elecfrical work at:
Job Addreu (Sheet, Box, o� Roufe No.) City Zip Code
�� 7-(-�, S-�' /t� �r ; � s�' `I 3.2
$eciion o. Township Name or No. Range No. Fire No. C nly
�C� � ��.���CA
o«�pa�r i, Pha,e No.
� �. � .S.�s s' ? � � s8 a�
Power Supplier Address
Elechi o�kacror (Company Name Conhacfor license ho. Master Lic. No. (Planf Elecl. Only)
I�CJ 7` R� 2�2 ���G t'�f : G i 1 � l�
Mailing Address (Conhactor or Owner P ing Insfallafion)
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Aufhorized ' n (Conh er Performi ns 'on) Phone No.
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E 1A-11 8/96 BpARD COP - SEE INSTRUCTIONS ON BACK OF VELLOW COav