P - 83381REQUEST FOR ELECTRICAL INSPECTION °'��
� J�-16 2� Minnesota State Board of Electricity s
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �`
' Phone(612) 642-0800 "�'
Home Duplex Apt. Bldg. Other: New Addn
Commerciai Industrial Farm Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
/�� G��i�i P�°�eY
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps Q to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTA� I�
Sign/Outline ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins the elechical installafion described herein on Ihe dates stated
Irrigation Boom Rough-In Dare
Speciallnspect' -
Investigative F � F�nal
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OfFICE USE ONLY This request void 18 months 6om validation date printed in this box. �
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* 0 6 9 1 1 6 2 2* �7�7
PLEASE PRINT OR TYPE
Reque ale Rough-in inspecfion required2 ❑ Yes No Inspec}ion Ofher Than Rougfrin: Ready Now ❑ Will Call
'�/3 � q (You musf call Ihe inspector when ready� Date Ready:
I, icensed contractor ❑ owner hereby request inspection of the above electrical work at:
Jo��!/ � �/ //.C��� C,y � �(M Zip Code
Section No. Township Name or No.
Occupant
Power S�pplier �
EI C a r(C y Nam �
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Mailing Address (Conhactor Owner Perfo ' Insta
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A oriz ignafu Conhacfor or Owner P/rfouninq
Phone No.
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Conkycfor Licen� No. ^_D� Masfer Lic
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COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY
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