P - 83287REQUEST FOR ELECTRICAL INSPECTION ���
5��'w C� 0 Minnesota State Board of Electricity
� '� 1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800
Home Duplex Apt. Bldg. Other: � —y New Addn
Commercial indusfrial farm ��� v Remod Re ir
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range c. Heat Temp. Service
"X" above the work covered b t is request. Enter remarks in this space and on the back of the white copy only.
�,�iit�G �D1T� -���n-�-� � ;
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Calculate Inspecfion Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circtirts/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Sfreet Lig./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR•S uSE� � �C/� $-_aU TOTA �
Sign/Oudine Ltg. Xfmr. � T .
Alarm/Remote,G _ ol
Swimming Pool��' `,,� �/�� -- �� �'j�'
I hereb cerli that I ins the elechi insfalfahon d ri in on the daMS s�
Irrigation Boom=� eo�Mo , —
Special Inspection' '
Firwi
Investigative Fee l�
THIS INSTALLATION MAY BE ORDERED DISCW�N�IECTED IF NOT COMPLETED WITHIN 1 MONTHS.
OFFICE U8E ONLY This r�qwst void 18 months Irom validation te printed in this box.
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* � 5 3 2 5 3 � 3�K pLEASE PRiNT OR TYPE �' �
Request Date Rough-i� inspection requiredZ es ❑ No Inspec6on O�er Than RougMn: eady
O ❑ R Now Will Call
/� g Q (You must call the inspecror when ready� Date Ready:
I, ❑ licensed contracror� owner hereby request inspection of the above elecirical work at:
1ob Address (Sheat. Box, or Route No.) Ciy Zip Code
5 I�B�.u��N rN� F�� �� 55�3z
Seclion No. Township Plame or No. Range No. Fire No. Counly A �
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o����� pr� 11� � �'l — �j �
P�. s���a. add.�
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Elecirical Contractor (C mpany Nome) Contractor license No. Masler lic. No. �Plant Elect. Only)
Mailing Address (Con or Owner Performing Instullation)
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Auiho�zed Signafure (Conhacror or er Performirg Ins Phone No.
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EB00001 A-11 8/96 �p� gpppp COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY