P - 84681A REQUEST FOR ELECTRICAL INSPECTION °p�.
4�; �= 2 4 9 Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re ir
Air Cond. Hfg. Equip. Water Htr. ad Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by ihis request. Enter remarks in this space and on the back of the white copy only.
Calculate Inspection Fee - This Inspection Request will not be accepied wifhout the correct fee:
Other Fee # Service Entra�ce Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traific Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTA� �
Sign/Outline Ltg. Xfmr. '��
Alarm/Remote Confrol
Swimming Pool
I he�eb certi }hat I ins ted the elechical installafion described herein on the dates stated
Irriqation Boom o,,..,.ti �., „_._
Investigative Fee � " � .y j !
_ THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This rec{uesf void 18 months (rom validafion dale printed in this box.
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* � 4 4 8 2 4 9 3�K EASE PRINT OR TYPE
Request Dafe RougMin inspection requiredZ es ❑ No Inspecfion Other Than RougMn: ❑ Ready Now Will Call
(p �p � (You musf call the inspector when ready) � Dafe Ready:
I, censed confractor ❑ owner hereby request inspection of the above elecfrical work at:
Job Address (Street, Box, or fe No.� � City ' Zip Code
l C���sj�so.d � �r�,t��
Section No. Township Name or No. Range No. Fire No. Counly //�
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��� Phone No.
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��TM�� � �"�' I Conhactor License No. I Master Lic. No. (Plant Elecf.
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Moiling Address �Conhactor or Owner rming�inslanation� - �
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AWhorized Signalur onkacior or Owner Performing Installation) �� � Phone No.
�: C
E&00001 A-1 1 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY