P - 82648,, REQUEST FOR ELECTRICAL INSPECTION
`tr'.�J� V- 9 0 2 Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �;
Phone(612)642-0800 " '
Home Duplex Apt. Bldg. Other: New Addn
Commercial- Industrial Farm Remod Re air
ir Co . tg. Equi . Water Htr. Load Mgmt. Other.
ryer (. Range Elec. Heat Temp. Service
"X" above the work covered y this request. Enter remarks in this space and on the back of the white copy only.
Calculate Inspecfion Fee - This Inspection Reques► will not be accepted withou► the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 00 Amp j 0 to 100 Amps
Street Ltg./TrafFic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL 5 O
Sign/Outline Ltg. Xfmr. S ^-
Alarm/Remote Control
Swimming Pool �-'j-�'�
I hereb certi fha( I ins ected the elechical insiallafion described herein on th ates sfaf
Irri9ation Boo RougMn � Date
Special Inspect' _ v"� � �'C' �6
Final �
Investigative Fee �%---�____ - � `
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WI IN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 months from validation date printed in fhis box.
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PLEASE PRINT OR TYPE
Request Date Rou h-in ins ection r uired? Yes pecf" g ❑ Ready Now Will Call
\w � �� 9 p e9 ❑ No Ins �on Ofher Than Rou han:
b(You must call the inspecfor wh n ready) Dafe Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sheet, Box, or Route No.) Ciry Zip Code
1�5 � � '
Section No. Township Name or No. Range No. Fire No. County
cC�pant . _ n , ` Phone No.
I Power uppliei
S
tlecirical Contractor �Company Name)
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Mailing Address (Conhacfor or ne�erTc
Authorized Signature �Conhactor o � �/ � 8 I p
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY
• �
Controctor License
Lic. No. (Plant Elect. Only)