P - 83792REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricit 1`
�� J� 9 5 6� 1821 University Ave., Rm. S-128, St. Paul, MN 55104 =
Phone (612) 642-0800 ''�'
I Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm
ir Cond. Htg. Equip. Water Htr.
Dryer Range Elec. Hea
I "X" above the work covered by this request. Enter
'vlgmt. Other:
Service
in this space and on the back
Remod
copy only.
Calculate Inspecfion Fee - This Inspection Request will not be accepfed 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 Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONIY TOT�L /
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
I hereb certi fhaf I ins cted }he electrical installation described herein on the dates stated
Irrigation Boom Rough-In �` _ � .��i! �f�G
Final ' e �
Investigative
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 monfhs from validafion dafe prinfed in ihis box.
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I IIII II ifl II III II III II III I III II III II III I�I�
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* 0 4 9 8 9 5 6 2* PRINT OR TYPE `i
Request Date Rough-in inspection required. Yes ❑ No Inspection Other Than Rough-In: ❑ Ready Now � Will Call
�'� � �You musf call ihe inspecror when ready) Dafe Ready:
I, icensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sheet, Box, or Roufe No.) �, "' ^ � Zip Code
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��t% L°i��15%�E'-�fS�!!�_ �• ��1 JC`� f =
Secfior No. Township Name or No. , anye No. - Fire No. w,
.. ,. �-� �:� ;
OccupQny� „ Phone No. ��
Pe.ver Suoplier
Electrical Conhacfor ICc
Address
� Conhactor License No.
IC. CA00381
� i r�u
463-: 310
,- . _
Masfer Lic. No.
No.