P - 82990� REQUEST FOR ELECTRICAL INSPECTION -_
J U 4- 613 Minnesota State Board of Electricity
� 1821 University Ave., Rm. S-128, St. Paul, MN 55104
1 Phone (612) 642-0800
Home Duplex Apt. Bidg. Other: New Addn
Commercial Industrial Farm Remod Re air
Air C Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this requesi. Enter remarks in this space and on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Reques� will not be accepted wiihout ►he correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to i00 Amps
Street ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY T` A4,�
Sign/Oudine Ltg. Xfmr. �
Alarm/Remote Control
Swimming Pool
1 cerli thof I ins the eleclrical installation described herein on the da�es sMled
Irrigation B Ra,qMo Dare
Speciallns '
Investigative Fee F�� -�,- .-�l�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validation dale printed in this box.
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PLEASE PRINT OR TYPE
R�t^ate ��-^� Ro FFin ins
j ���� og pec�ion required$ ❑ Yes No Inspection O�er Than RougMn: Ready Now � Will Call
� � �You must call the inspec�or when ready) Date Ready:
I, 'censed contractor ❑ owner hereby request inspection of the above elecMical work ah
Jo Address (Sheef,p x, a Route No.) C�», Z�p C�
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Secfion No, Townshi Name or No. Ronge No. Fire No. Counly
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�� Phone No.
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Power Supplier qadreu
Elechi onhrntor Name .� Contractor License No. AAosfer lic. No. (Planf Eled, Only)
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Mailing��ss Con� e�erforming In�fion) ( -/,/J� I�-. ) .
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Authoriz 'gnature ( nhaclor or ing I Ilafion) .,�� :. � Pho No.
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E&OOQOIA-11 8/96 y�p� gOARD COPY - SEE INSTHUCTIONS ON BACK OF YELLOW COPY