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Home Duplex
Commercial Industrial
W.IY
RE(�UEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
Apt. Bldg. Other: New
Farm Remod
Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service �! 1 �/ ,Yy�
request. Enter remarks in this space and n the back of t e white copy
Calculate Inspection Fee - This Inspection Request will not be accepted withoui the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders
Mobile Home Park Stall to 00 Amps 6' 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Ar
Transformer/Generator INSPECTOR'S USE ONLY TO �
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
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only.
Fee
I hereb certi that I ins ted the elechica) install fion dexribed herein on the dates stated
Irri9ation Bo RougMn D ��
SpeciQl Insp i . � � �'v
Final fe c
Investigative Fee - Z— p
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 ONTHS.
OFFlCE USE ONLY This requesf void 18 months (rom validafion date printed in ffiis box.
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I III) II III II III I� II) II III I� II I III (I III I IIII -�7
* � 4 9 8 9 7 1 Z�K PLEASE PRINT OR TYPE �`5 -S�)
Request Dafe � Rou h-in ins tion r uired? Yes
—� g pec eq ❑ No Inspection 01her Than RougMn: ❑ Ready Now Will Call
`f (You must call fhe inspector when ready) Date Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sfreet, Box, or Route No.) Ci Zip Code
��J %� l�'i'i2.1 S7 52r1�! L-c, - ��\ 1� L-'2
Secfion No. Townshio Name or No. Ranae No_ Fire No_ Coun
OCCu
6Z1'C t,vy�lj
Power Supplie� � ^ Address
1(
Elechical Contracror��yft��TR�C, INC. CA00381 Contracror License Nc
310G-225TH ST. W., FGTtd., W1N 55024
Mailing Address (Conk�ctor or Owner PAformingJpsta afion)
or
E&00001 A-11
4 (;
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Phone No.
Master Lic. No. (Plant Elecl. Only)
No.