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P - 82040� � REQUEST FOR ELECTRICAL INSPECTION � � ° � � � � � � (� � Minnesota State Board of'�Electricity � � � J 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 = e (651) 642-OS00 www.electricity.state.mn.us '��' Home Duplex Apt. Bldg. Other: New Addn Commercial Industrial Farm Remod Repair Air Conditioner Hig. Equip. Water Htr. Load Mgmt. Other. Dryer Range Elec. Heaf Temp. Service "X" above tl�e work covered by this request. Enter remarks in fhis space and on the back of the white copy only. Calculate Inspection Fee - This Inspection Request will no► be accepted wiihout fhe correci fee: Other Installations Fee # Service Entrance Size Fee # Circuifs / Feeders Fee Mobile Home Park Stall 0 to 200 Amps 2 0 to 100 Amps Street Ltg. / TrafFic Sig. Above 200 Am s Above 100 Amps Transformer/Generotor INSPECTOR'S USE ONLY TOTAL � Sign / Outline Ltg. Xfmr. �O S Alarm/Remote Control Swimming Pool I hereb certi that I ins ected the electrical installation described herein on the dates stated: �ffl94flOf1 BOOfII � Rough-In . .. � Date Special Inspect � Final Dat - Investigative Fee ` THIS INSTALLATION MAY BE ORDERED DISCONNEC7ED IF NOT COMPLETED WITHIN 18 MONTHS. �_ � OFFICE USE ONLY This request void 18 months from validation dafe prinfed in fhis box. l���lll�lillillluillil�li�lll��l� • a/p���[ * D 8 9 3 3 6 9 9* (;1✓7 PLEASE PRINT OR TYPE Request Dafe Rough-in inspecfion required? ❑ Yes ,*lo Inspection Other Than Rough-In: Ready Now 0 Will Call �i ���Q � You must call the inspecfor when ready Date Ready: I,'� licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at: Job Address (Sfreef, Box, or Roufe No.) � City � Zip Code ��O — �i'� l� ST. XE Fr,a✓�e Section No. Township Name or No. Range No. Fire No. County � k0 F� Occupanf Phone No. „�a�na (2ec�Pc�eH Power Supplier Address � Elechical Contracror / Company Name - Contracfor license No. Master Lic. No. (Wani Elect. Only� �-rs ������ ��a �y� Mailing Address (Contractor, Company or Owner Performing Insfallafion� ���o -�s � t� � � �u c✓ ��.,,;,.,► . �!'IH . .ss39� Aufhorized Signafure �Confractor, Company or Owner Performing Insfalla 01 Phone Number ( ) / 3a EB-00001A-12 5/1999 STATE RD PY SEE INSTRUCTIONS ON BACK OF YELLOW COPY