P - 83961REQUEST FOR ELECTRICAL INSPECTION -
� 4�,� �± /� Minnesota State Board of Electriciry
8- 9�� "t 0 1821 University Ave., Rm. S-128, St. Paul, MN 55104
e, 612) 642-0800 ' '
Home Duplex Apt. BI . Other: ��,` New Addn
Commercial Industrial Farm Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
Calculate Inspection Fee - This Inspeciion Request will not be accepfed withouf the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR�s use oN�r TOTAL
Sign/Outline Ltg. Xfmr. � S
Alarm/Remote Control
$wimming Pool
I hereb certi that I ins ted the electrical installation dexribed herein on the dates stated
Irrigation Boom Rough-In Dare � � •
Special Inspecti C"—�' C� �`' -�?
Final � D
Investigative Fee �-__.--.- �=� —�„ - G�--
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTH .
OFFICE USE ONLY This requesf void 18 months from validafion dafe prinfed in fhis box.
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* � 4 9 8 9 6 4�� PLEASE PRINT OR TYPE l��
Request Date Rou h-in ins fion r uired? Yes
g pec eq ❑ No Inspection 01her Than Roughan: ❑ Ready Now Will Call
1 T�� O �Q� (You must call the inspecfor wh ready� Date Ready:
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I, �icensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address �Sheet, Box, or Roufe No.) City Zip Code
\ -1-1 `�a- .
Section No. Township Name or No. Range No. Fire o. Co�ty _
No.
Power Supplier
Electrical Contractor �Company Nam��T�ES ELECTFj�C� �(�jL`. I Cq�A�� nse No.
310G-22bTii ST. W., FGTTV.. MN 55024
Mailing Address (Conhactor or Owner��p rming Insfall�o n)
17�_ _ 1 � �
or vwner rerrorming insrananon�v 2 5 6 t� `� I r
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY