P - 80756REQUEST FOR ELECTRICAL INSPECTION �
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5� r'j � C; Q Q m Minnesota State Board of Electricity
L �� `� �� 1821 University Ave., Rm. S-128, St. Paul, MN 55104
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Phone (612) 642-0 0
Home Duplex Apt. Bldg. Other: � New Addn
Commercial Industrial Farm �// Remod Re air
Air Cond. Htg. Equip. Water Hh. Loa Mgmt. Other: h'C�.7`QI� $�' e
D er Range Elec. Heat Temp. Service Gt� r uKdQ� ���
"X" above the work covered by this request. Enter remorks in this space ond on �he back of Ihe white copy only. �G
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Calculate Inspection Fee - This Inspecfion Request will not be accepted wifhout the correct fee:
Other Fee # Serv" rance S'ze Fee # Circuits/Feeders Fee
Mobile Home Pork Stall t 2 ps � 0 to 100 Amps
Street Ltq./Traffic Siq. Above 200 Amps Above 100 Amps
Sign/Oudine Ltg. Xfmr. "�v
Alarm/Remote Controt 1/ s�
Swimming Pool °�
I h�v i the eleclrical installation described herein on the da�es swled
Irrigation Boom R«�M oo�
Special Inspection
Finol ,�� �
Investigative Fee �i� '—L..�-�
THIS INSTALLATION MAY BE ORDERED DISCONNlC'T!R! ! NO'T G�'I.ET[D WITHIN 18 MONTHS.
� OFFICE USE Olr.r 711n �sqw# void 18 n�oMl+s from wlidafion dafe printed in this box.
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I II III II III I IIII 3�� �
* 0 5 3 2 5 9 9 8* pLEASE PRINT OR TYPE
R�=�°� ^/J/aI Rough-in inspection required? ❑ Yes No Inspeclion Olher Than RougMn: Ready Now ❑�II Call
�� o`� 7� (You must call the inspeclor when ready) Date Ready: � l �
I, ❑ licensed contractor �owner hereby request inspection oF the above elecirical work at:
Job Address (Sfreet, Box, or Roufe No.) Ciy Zip Code
�� �rThur S� IY�. —r�d(ey �!/( �'k�3�.
Seclion No. Township Name or Range No. Fire No. Counly �
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Oaupant phone No. '
� ,��-�� �-��e��r , s���-T2 ���—z83��� � z
Conhaclor License No. � Masler Lic. No.
Mailing Address (Con edor w Owner PerF
Authorized SignaturBj�Conhac�or or Owner
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STA7E BO D Y- SEE INSTRU ON BACK OF YELLOW COPY