P - 84626:...-�
' REQUEST FOR ELECTRICAL INSPECTION -
�� /� �:,.c, �� Z Minnesota State Board of Electricity
�r 1821 Uni��ersity Ave., Rm. S-128, St. Paul, MN 55104
� Phone (612) 642-0800
Home Duplex Apt. Bldg. Ofher: New Addn
Commerci Indushial Farm Remod Re air
ir Con ig. Equip. Water Hfr. Lood Mgmt. Other:
Dryer Range Elec. Heat Temp. $ervice
"X" above the work covered by this request. Enter remarks in ihis space and on ihe back of the white copy only.
Calculate Inspection Fee - This Inspeciion Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 00 Amps 0 to 100 Amps
Street Lig./Tra$ic Siq. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TQTAL
Sign/Oudine Ltg. Xfmr. `� 'b �;
Alarm/Remote Conhol
Swimming Pool
I hereb cerli that I ins ted the e frical installation described herein on the dates sfafed
Irrigation Boom Ro� Mn
9 Da
Speciallnspecfio -- j�%
Final � �
Investig�tive Fee
THIS IN�TALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONT'HS.
� OFFICE USE ONLY This requesT void 18 monfhs from validafion date prinled in ��is box.
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� 0 4 4 8 2 3 2 9* ��'�
LEASE PRINT OR TYPE
Requesf Date Rou h-in ins tion r uired2 Yes
� g pec eq ❑ No Inspection Olher Than RougMn: ❑ Ready Now Will Call
(You muzf call the inspecror when ready) Cafe Ready:
I, icensed contractor ❑ owner hereby request inspection of the above elechical work at:
Job !fl�jrys�heet, Box, w Roufe N`.) - City � � Zip Code
I�
Section No. Township Name or No. Range No. fire No. Counly
Occupqgt� _ _ „ , Phone No.
�vs � -
Eleckical Conhy���r�qr��rt��C''�. Conhactor License No. Iv
�r� 11 CLt CA00381
S10�r22�Tii ST. W
Moiling Address �Conhacfor or Owner Perforn�'�n�
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