P - 83153, REQiJEST FOR ELECTRICAL INSPECTION
��a�, Q O �,` Minrtesota State Board of Electricity
J V O U 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 ir
Air Cond. Htg. Equip. Water Htr. Lpod Mgmt. Othe!:
Dryer Range Elec. Heat Temp. $ervice
"X" above �he work covered by this request. Enter remarks in this space and on �he back of ihe white copy only.
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Calculate Inspection Fee - This Inspection Request will noi be accepfed without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps ro 100 Amps �
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Trans{o�mer�Gene�ator INSPECTOR'S USE ONLY TOT�
Sign/Outline Lig. Xfmr. � � � � ��
. �
Alarm/Remote Conhol `
$wimming Pool
I here certi 11wt I in 1he electrical installafion described herein on the do�es swted
Irrigation Boom RoogMo D�e
Special Inspection
F'nal
Investigative Fee Z0.
THIS INSTALLATION MAY BE ORDERED ECTED tF NOT COMPLETED WITHI 18 MONTHS.
� �FPK� lJSE OIILY This requesf void 18 moMhs from vaiidafion dale prinfed in this box.
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* � 5 2 3 8 8 6 ��k PLEASE PRINT OR TYPE
R��� R h-in ins on r uired$ ❑ Yes
� °U9 P�� eq ❑ No Inspeclion Other 7han RougMn: Ready Now O�11 Cull
(You musf rnll the inspector when reody) pate Ready,
I, �icens conhactor ❑ owner hereby request inspection of the above elech�ical work ot:
1ob Ad�s Sheet, Box, or Roote No.) � Ci � Zip Code
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Section No. Township Name or No. � Range No. Fire No. C
,�A!�K+4
� Occupanf . Phone No.
C�� T�u c.c_, s7a - 9s°8q
Power Supplier . Address
�tls P
Elecfrical Co�hacror (Company Name) Conhactor ticense No. Moskr Lic. No. �PIcM Elec1. Ortly)
� C�-�S�- � C�/� C�-o �6 S
Mailin Address (Conhncfor or Owner Performirg Insfallafion�
� � T�2�2�TD ''114C_ �� S'�.
Authori Signature (Conhacfor or Owner erformin Insta 'on) • Phone No.
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'a"° -' STATE OARD COPY - SEE INSTRUCiIONS ON BACK OF YELLpW CppY