P - 81745�.� 2 �- 2 51 �
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)C Home Duplex
Commercial Industrial
Air Cond. Htg. Equi
Dryer Range
"X" above the work covered b
REQUEST FOR ELECTRICAL INSPECTION °'E
Minnesota State Board of Electricity a
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �:
Phone (612) 642-0800 ,�� `���
Apt. Bldg. Other: � �� S� New Addn
Farm Sd Remod Re air
Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
►his request. Enter remarks in this space and on the back of the white copy only.
Calculate lnspection Fee - This Inspection Request will not be accepted without ihe correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Sheet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOT/��/ �
Siqn/Outline Lta. Xfmr. !
Alarm/Remote Control
Swimminq Pool
that I ins the eleclrical installation described herein on ihe dates slated
Date �—Q ,
°° �- 2 ^ i�
Investigative Fee = _, v.
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 16 monihs from validation dafe prinTed in this box.
IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIi�IMlillllllillllll ��j�
* 0 8 0 2 2 5 1 9* � `I'•��
PLEASE PRINT OR TYPE
Request Dote R h-in ins ion uired8 Yes
oug pecY req ❑ No Inspeclion Other Than RougMn: ❑ Ready Now ill Call
,3 �a.� �(j �You must mll the inspector when ready) Date Ready:
I, ❑ licensed contractor �owner hereby request inspection of the above elecfrical work at:
Job Addreu (Street, Box, or Roufe No.) City Zip Code
��5.�' - %i� S� . �r i � % v'��{3 �-
Seclion No. Township Name o. Range No. Fire No. C nly
�D � R'� n o� n/o ft
Occupant /� Phone No.
�C,v�.d ffi� /�1�/��0 /C-4E�i�t/G 7L3-S 7/-7D.S2`
Power Supplier �� � Addreu � � �
�JlS�o�J
Electriwl Confrayel��pmpany Name) Conhacror Lice�se No. Master Lic. No. (Plant Elect. Only�
Mailing
a
Qr Owner
/ �!/��–
STATE BOARD COPY - SEE STRUC770NS ON BACK OF YELLOW COPY