P - 8476940�-918
i
Home Duplex
Commercial I ndustrial
Air Cond. Htg. Equ
Dryer Range
"X" above the work covered 6
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity -
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
. Other. New Addn
Farm
Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
request. Enter remarks in this space and on
of the white copy only.
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders
Mobile Home Park Stall to 00 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Abo e 200 Am s Above 100 Ar
Transformer/Generator INSPECTOR'S USE ONLY TOT,
Sian/Oudine Lta. Xfmr.
Fee
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Swimming Pool
I hereb certi that I ins ected the eleckical installafion dexribed herein on the dates stated
Irrigation Boom RougMn Da�e
Special Inspecti ( . �.. '�� —����
Final D q�
Imestigative Fee �" �� `
THIS INSTALLATION MAY BE ORDERED DISCONNECTED fF NOT COMPLETED WITHIN 18 MONTHS.
OFflCE USE ONLY This mqvest void 18 months kom validation date prinfed in this box.
�����I���I��I�I���I�O��I�� �����I����� ��� �
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* � 4 � � 9 1 8 9* LEASE PRINT OR TYPE
Requesf Dafe Rou h-in ins fion r uired? ❑ Yes pecli g ❑ Ready Now Will Call
9 P� eq ❑ No Ins on Other Than Rou Mn:
�,.. �, �� �You must call the inspector when ready� Date Ready:
I, icensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Addreu (Sheet, Bo or Route No� City Zip Code
l 33 � N-�isT�� �� IC� loc..�
SecFion No. Township Name or No. Range No. Fire No. County �
��aK
Occupant Phone No.
C/ L(,(�yJ
Power Supplier Address
���
I Conhaclor
n�tc. caoa�s�
(Conhactor or Owner Perfor�
� I �' •
Master Lic. No. (Planf
vwner rq�emm9�ro�y/��g^Io Cti ,-�� � I Phone No.
U �1 �1 . �
STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY