P - 82715� �..
REGIUEST FOR ELECTRICAL INSPECTION -. EB-0000i-os
"��� '� , j� � See instructions for completing this form on back of yellow copy. �
`� , (� ��l „X" Below Work Covered by This Req st
..
e Add Rep. Type of Building Appliances Wired Equipment Wired
Home Range Temporary Service
Duplex Water Heater Electric Heating
Apt. Building Dryer Load Management
Comm./Industrial Furnace Other (Specify)
Farm Air Conditioner
Other (specify) Contractor's Remarks: CyjL C< «5 t+K e xT �u-"'i �� f� "'�
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Compute Inspection Fee Below:
# Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Swimming Pool 0 to 200 Amps 0 to 100 Amps
Transformers Above 200 Amps Above 100 Amps
SIgI1S InspectoYs Use Only: TOTAL
trrigation Booms
Special Inspection
Alarm/Communication THIS INSTALLATION MAY BE ORDERED
Other Fee COMPLETED WITHIN 18 MONTHS.
I, the Electrical;,;lnspector, hereby Rough-in
certify that the a i has F;nai
been made. �,��, �
OFFICE USE ONLK. �" � �
This request void 18 monihs,from� � �
S7�
---_-----
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0-187- 4 � �i
Request Date Fire No. Rough-In Inspection Required In ction Other Than Rou
(YOU must �spector when ready) � Ready Now ill Notity Inspector
� es ❑ No Date Read
I❑ licensed contractor �ner hereby request inspection of above electrical work at:
Job Address (Street, Box or Route No.) City
�OZ \ g C C�.r'�O ` �JI,K� � �('ti d �
Section No. Township Name or No. Range No. County `' �
� �`�i�
Occu ant(PRINT) Phone No.
� ��-=.�— !`o` . IV\ou�1.� 57�-14� 8`�-
Power Supplier Address
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Electrical Contractor (Co pany Name) � Conhactor's License No.
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Mailing Address (Contrac Owner Making Installation)
Authorized Signature (Contractor/Owner Makinc,�ln`stalla
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MINNESOTA STATE BOARD OF ELECTRICITY ( IIII
Griggs-Midway Bldg. - Room 5-128 II
1821 University Ave., St. Paul, MN 55104 N
Phone (612) 642-OS� II
, Phone Number
�_�. � 2 �� ��g�.-
�(I III�� (III) II�II I��II IIII) IIIII THIS INSPECTION REQUEST WILL NOT
BE ACCEPTED BY THE STATE BOARD
UNLESS PROPER INSPECTION FEE IS
ENCLOSED.