P - 77196�0-�-359
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RE(�UES�. FOR �L.ECTRICAL INSPECTION ��:. ..
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �.
Phone(612)642-0800
Other. New Addn
ommercia n ustria 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 remar in this�pace an� the back of the white copy only.
O�l�— �
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Calculate Inspection Fee - This Inspection Requesi 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 0 to 100 Amps
Street Ltg./Traffic Sig. ve 200 Amps Above 100 Amps
Transformer/Generator R'S USE ONLY TOTAL
Sign/Outline Ltg. Xfmr. 'Z„t - 'S �
Alarm/Remofe Control
Swimming Pool �
,� b erti fhat I ins cted the electrical installation described herein on fhe dafes stated
Irrigation Boom �, pa�
$pecial Inspecfion /`( rn � `J- ' 1 �' °�
�
Investigative Fee 3'—�/- o t,� ��� r�Y .�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 1 MONTHS.
.. OFFICE USE ONLY This request void monfhs 6om validation dafe prinfed in fhis box.
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PLEASE PRINT OR TYPE �� 5C�
Requesf Dafe Rough-in inspection required? ❑ Yes
❑ No Inspection Other Than Rough-In: ❑ Ready Now ❑ Will Call
(You musf call the inspector when ready) Date Ready:
I, ❑ licensed contractor �owner hereby request inspection of the above electrical work at:
1ob Address (Sheet, Box, or Route No.) �� Ciry � Zip Code
O O r� N r� S� 5° �—
Secfion No. Township Na or N. Range No. Fire No. County
N �
^� ,� Phone No.
a,�r � a-w ��►-�t � �� — 0 3
Power Supplier Address
L' � � �� r�� � a-o n� L
Electrical Conhacfor (Company e) Contractor License No. Master Lic. No. �Planf Elect. Only)
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Mailing Address �Conhacfor or Owner Performing Installation)
Aufhorized Signature (Conhactor or Owner Performing Insfallation) Phone No.
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E&00001 A-1 1 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY