P - 77866REQUEST FOR ELECTRICAL INSPECTION ,`..w EB-00001-03
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�Q ���' See instructions for completing this form on back of yellow copy.
X low Work Covered by This Request
Ne Add Rep. Type of Building Appliances Wired Equipment Wired
Home Range Temporary Service
Duplex Water Heater Lightiny Fixtures
Apt. Building Dryer Electric Heatin
Commercial Bldg. Furnace Silo Unloader
Industria) Bldg. Air Conditioner Bulk Milk Tank
Farm Other pecifY ther (SUecify)
t erlSpecify Other Other
Compute lnspeciion Fee Below
� Fee ServiceEntranceSize # Fee Feeders/Subfeeders it Fee Circuits
Oto100Am s Oto30Am s Oto30Am s
101 to 200 Amps 31 to 10Q Amps 31 to 100 Am s
Above 200 Amps Above 100 Amps -/11'� Abov 100 Amps
n(,-'fT47 f KS
Rough-in
Fihal
Th s request void
1B n�onths from
Remote Control Circ.
Special Inspection S
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e
Partial%Other Fee
TOTAL FEE
I, the Electrical
Inspector, hereby
certify that the above
inspection has been
made.
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This request void �
18 months from � Q�/ Z
�_�l� � - �-� � r�
7 ['%
Request Date Fire No. Rough-in InsU c i n
�^ I-�� �� Required? Ready Now Q Will NotifV. Inspec-
❑ Yes ❑ N� tor When Ready
� Licensed Elec[rical Contractor I hereby request inspection of above
Owner electrical work installed at:
Street Address, Box or Route No. City
6 % � �a 5%T� ti � � /�� � f
ecvon o. Township Name or No. Range No. County I
Occupant (PRINT)
� � �' � /� � Lo�a r'l
Power Supplier Address
� �
Electrical Contractor (Company Name)
s�"� �
Mailing Ad�ress ICont tor or Owner Making Instailation)
�
Authorize� Signat�e (Contractq�Ovy�er Making Installation
MINE��OTA STAfE BOARD OF�LECTRICITY
Griggs-Midway Bidg. — Room N-191
1827 University Ave., St. Paul, MN 55104
Phone (612) 297-2111
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Phone No.
s7y- 7 yY�
Contractor's License No.
Phone Number
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THIS INSPECTION REQUEST WILL NOT
BE ACCEPTED BY THE STATE BOARD
UNLESS PROPER INSPECTION FEE IS
ENCLOSED.