P - 80649, REQUEST FOR ELECTRICAL INSPECTION -
�C, /� ��/I � Minnesota State Board of Electricity
�� `'f �� 1821 University Ave., Rm. S-128, St. Paul, MN 55104
. Phone (612) 642-0800
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter 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 accepfed w
Other Fee # Service Entrance Size Fe
Mobile Home Park Stall 0 to 200 Amps
Street Ltg./Traffic Sig. Above 200 Am s
Transformer/Generator INSPECTOR'S USE ONLY
Sign/Oudine Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
I hereb certi thaf I ins the electrical
Irriaation Boom o,.,,,.��:.
the correcf fee:
# Circuits/Feeders
0 to 100 Amps
Above 100 Ai
F�
C�a' �J
installation described herein on the dates stated
THIS INSTALLATION MAY BE ORDERED DISCON��CTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 monfhs (rom validation daffi prinfed in fhis box.
I I�II II III II III II III II III II�MIN II III I� lll I I�I •�J� -�a
* 0 6 6 4 3 4 2 3* ,`l3�
PLEASE PRINT OR TYPE �f
Requesf D-fe �`�� Rough-in inspecfion required$ es ❑ No Inspecfion Olher Than RougMn: eady Now ❑ Will Call
r
�You musf call ihe inspeclw when ready) Date Ready:
I, �licensed contractor ❑ owner hereby request inspection of the above elecfrical work at:
Job Address (Streef, Box, or Rou�e No.� Ciy Zip Code
� � t '' 4
Secfion No. Township Name or No. Rarge No. Fire No. County
0
Power Supplier
No.
il Conhacto� (Company NameL Conhacfor License No. �
�nE L� n� � Ltc� CJ�o �3�
Addreu �Conhaclor or Owner Performing Insfallafion� .
5 R� 1• C, E
. Sign (Conha Owner P rming Insfallafion) A�! {�� p
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1A-11 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY
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