P - 80389�
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Home Duplex
C o m m e rc i a l I n d u str i a l
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RE�UEST FOR ELEGTR�CA� INSP�TION -
Minnesota State Board of Electricity
1821 University Avenue Sui[e S-728, Saint Paul, Minnesota 55104-2993 =
(651) 642-0800 www.electricity.state.mn.us `'�'
Apt
WaYer Htr. Load Mgmt. Other:
Elec. Heaf Temp. Service
is request. Enter remarks in this space and on the back of the white copy
Calcula►e Inspection Fee - This Inspection Requesi will not be
Other Insiallations Fee # Service Entrance Size Fee
Mobile Home Pork Stall 0 to 200 Amps
$treet Ltg. / Traffic $ig. Above 200 Amps
Transformer/Generafor INSPECTOR'S USE ONLY
Sign / Outline Ltg. Xfmr. N� g-�t- � t
Alarm/Remote Control
Swimmin Pool
� without the correct fee:
Circuits / Feeders
0 to 100 Amps
Above 100 Amps
9 I herebvi certifv Fhaf I insoected the elecfrical insfallafion described
Date
Investigative Fee �� � v I V�%�— .3�GZ-- �
THfS 1NSTALLATION MAY BE ORDERED DISC CTED IF NOT COMPLETED WfTHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months 4rom volidotion dale printed in Ihis box.
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* 0 9 0 8 3 3 8?* ���ip�
PLEASE PRINT O TYPE
R�uesf Dpfe `� Rough-in inspecfion required? ❑ Yes o Irtspection Other Than Rough-In: Ready Now 0 Wil! Call
� You must ca�l the inspector when ready Ddte Ready:
I, licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address Sheet, x, or Roufe No.� City Zi Code
C� ��� r��� C.�t�-r � - -el { : �3�
Section No. `` Towns ip Name or No. Range No. Fire No. County .
Occu��ant
� � Ca� �,.�.-r � ��
Power Supplier �
ical Contracror / Company Name
;-If—` � cz C.I�C
ig Address �Conhoctor, Co ny or Owner Perf
� S 5� rri=� ��.C!'
�rizecliSignature (ContractA[,� Company or� Owner
0
,J�t,�.-..1
STATE 80ARD COPY
Phone No.
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�g Insrollation� Phone Num
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SEE INSTRUCTIONS ON BACI
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OF YELLOW COPY