P - 80225,� • REQUEST FOR ELECTRICAL INSPECTION �_.
��. j--- ��°� � Minnesota State Board of Electricity
L `� 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" nbove ihe work covered by this request. Enier remarks in this space and on the back of the white copy only.
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Calculate Inspection Fee - This Inspeciion 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 -�
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOT L 1
Sign/Outline Ltg. Xfmr. �"
Alarm/Remote Control
Swimming Pool
I hereb cerTi that I' cted the electrical installation described herein on the dares stated
Irrigation Boom RougMln Da�e�
Special Insp i+ - r �_��
Fdaal� Da
Investigative "'Z- F �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request wid 18 months from validation date printed in lhis box.
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PLEASE PRINT OR TYPE
Request Date Rough-in inspection required$ ❑ Yes No Inspeciion Other Than Rough-In: ❑ Ready Now �� Will Call
I�as �� (You must call the inspedor when ready) Date Ready: �� 3.� vO
I, '�licensed contractor ❑ owner hereby request inspection of the above elechical work at: ••
Job Address (Street, Box, or Roule No.) Ciiy � Zip Code �- �
1�10�. ` Q 5 Z
$ecfion No. Township Name w No. Range No. Fire No. �
Power $upplier J � Address
Elechical Conhactor �Company N � ContraMOr License
p�u��tf�or�d eleEtri� inc. !�� �
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Mailing Address (Conkackk or u' w�'
i �fne�polity � 55410 ,
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Phone No.
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or r r rrormmg instananon) /. � � a.{ J rnone rvo. `pk(T
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY