P - 84338�00-�16 -„m
Home Duplex
Commercial Industrial
Air Cond. tg. Equ
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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 Remod Repair
Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
ihis request. Enter remarks in ihis space and on the
copy only.
024�6:?
Calculate Inspection Fee - This Inspection Request will noi be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Sroll 0 to 00 Amp 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL �
Sign/Outline Ltg. Xfmr. �
Alarm/Remote Confrol
Swimming Pool
I hereb certi that I ins ed the elec}rical installation described herein on the dates stated
Irrigation Boom RougM� /� Dare
Special Inspection � � '/ � � � �
F��ai , s �t ���
Investigative Fee °
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OF CE US O Y hi��aquest void 18 monfhs from validation date printed in fhis box.
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( ���� �) �I� �� ��I �� ��� �� ��� �� ��� ��) �I ��� � ���� �
* 0 4 � � 9 1 6 3* PLEASE PRINT OR TYPE
Requesf Dafe Rou h-in ins tion r uired? Yes
g pec eq ❑ No �nspection Other Than Rough-In: ❑ Ready Now Will Call
'..,,, 9�� �You musf call the inspecfor when ready) Dafe Ready:
I, �licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sfreef, Box, or Rouffi No.� Ci Zip Code
ly5 � ,
Section No. Township Name or No. Range No. Fire No. County
-�—�CS�.�
OqEilpant %1 � . Phone No.
bntractor (Company Name� �� �. � Cor �c ' gs
s�oo-� sr. w.. �TM � ssaia
dress (Conhactor or Owner Performing Installati )
� �
Signature �Conhoctor or ner PerFormi nsta ahon
1 1 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BAC