P - 84495_ REQUEST FOR ELECTRICAL INSPECTION -�..
4(� (-'� �(] �� Minnesota State Board of Electricity
«� �7 1821 University Ave., Rm. S-128, St. Paul, MN 55104
' Phone (612) 642-0800
Home Duplex Apt. Bldg. Other: New Addn
Commerciai industrial Farm mod Re ir
Air Cond. t. Equip. Water Htr. Load Mgmt. Other:
ry g-- " Elec. Heat Temp. Service
"X" above ihe work cover y this request. Enter remarks in this space and on the back of the white copy only.
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrancg ize Fee # Circuits/Feeders Fee
Mobile Home Park Stall to 00 Am ,� 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY T��,OTAL
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ted the elechical installafion dexribed herein on the dates stated
Irrigation Boom Rough-In . Date
Speciallnspecti " �
Final Dafe
Investigative Fee �-�—.- � �'��
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
� OFFlCE USE ONLY This requesf wid 18 months from validation dafe printed in this box.
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EASE PRINT OR TYPE
Requesf Date Rou h-in ins Kon r uired? Yes
g pec eq ❑ No Inspecfion O�er Than RougMn: ❑ Ready Now ❑ � a I
� O�. � 7 (You must call the inspec�or when ready) Date Ready:
I, icensed conhactor ❑ owner hereby request inspection of the above electrical work at:
Job Address �Sheet, Box, or Route No.� Ciy Zip Code
� C� 5 �`' � ��a��
Secfion o. Township Name or No. Range No. Fire No. Coun �
/(�a�'i�
OccuBpqi Phone No.
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ar�s � wc. Q�eoo�i
1 7�+ ST fGTN.. MI �
Mailing Address (Conhactor or Owner Perf afion)
V � ' •
Owner/�rlErming Insfallafion� �� 0�� I Phone No.
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY