P - 84496��� -923
Home Duplex
Commercial Industr
Air Cond. Htg. E<
Dry � Rang
"X" above the work covere
REQUEST 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 Addn
Farm Remod Re air
Water Hfr. Load Mgmt. Other:
Elec. Heat Temp. $ervice
this request. Enter remarks in this space and on the back of the white copy only.
Calculate Inspection Fee - This Inspection Request will nof be accepted wiihout the correct fee:
Other fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 00 Am 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR�S usE oN�v TO�AL �
Sign/Oudine Ltg. Xfmr. •+�
Alarm/Remote Confrol
Swimming Pool
I hereb cerfi that I ins the eleclrical insfallafion described herein on the dales sfated
Irrigation Boom RougMn pa
Special Inspecti --Z 8�^�
Final pa�
Imestigative F .�. •,-_ �7
THIS INSTALLATION MAY BE ORDERED DISCOH ECTED IF NOT COMPLETED WITHIN 1 MONTHS.
OFFICE USE ONIY This request void 18 months 6om validation date printed in this box.
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I IIII I) III II III II III II III I� III II III II III I� III I I�I � ��_ ��
* 0 4 0 0 9 2 3 9 * ����
PLEASE PRINT OR TYPE
Request Dafe Ro h-in ins fion uired?
ug pec req Yes ❑ No Inspeclion Olher Than RougMn: ❑ Ready Now Will Call
� .� �You must call the inspec�or when reody) Date Ready:
I, licensed confractor ❑ owner hereby request inspection of the above elecfrical work at:
Job Addreu �Sheet, �ox, or Route No.k r City � Zip Code
C� ls� S ����`
Section No. Township Name or No. Range No. Fire No. Cou
No/{�
Occu Phone No.
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Power Supplier+ Address
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Electrical Con��or�any Name� Conhaclor License No. Master Lic. No. (PlanT Elecf. Only�
CLECTRIC, fl�(�,. ��
310fr226Ti�1
Mailing Address (Conhac�or or Owner PerForrpgj�y(jon)
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Authwized ' noture �Con r o ing Insfallalion, . 2�� 4� Phone No.
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EB-00001 A-11 8/96 STATE BOARD COPY - SEE INSTAUCTIONS ON 6ACK OF vE��[fw [x�av