P - 83457REGIUEST FOR ELECTRICAL INSPECTION �
�� ��� � Minnesota State Board of Electricity
;. 1 1821 University Ave., Rm. S-128, St. Paul, MN 55104 �
Phone (612) 642-0800 `�'
Home Duplex Apt. Bidg. Other: New Addn
Commercial Industrial Farm Remod Re air
' C Htg. Equi Water Htr. Load Mgmt. Other:
Dryer Rang Elec. Heat Temp. Service
"X" above the work covere by 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 # ervice Entrance ize Fee # Circuits/feeders Fee
Mobile Home Park Stall to 00 Amp 0 to 100 Amps
Sheet Ltg./Traffic $ig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECroR'S USE ONLY TOT� 5 5d
Sign/Oudine Ltg. Xfmr. u � �
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins the elec ' I insrollation described herein on the dates stated
Irrigation Boom eo�Mo � Date �
Specia� Insp ` Final Dar�—Z - 9
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validafion dafe prinfed in this box.
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*D6787C197� �l3/
PLEASE PRINT OR TYPE
Requesf Dafe � R I�in ins on uired$ es
oug pecti req ❑ No Inspection Other Than RougMn: ❑ Ready Now ill Call
`� � (You must call the inspeclor when ready� Date Ready:
I, licensed contractor ❑ owner hereby request inspection of the above elecfrical work at:
Job Address �Sheet, Box, R No.� � City � Zip Code
Secfion No. Townshio Name or No. anae N_ Fire No_ G���w • _
EIE�ctric4YConhactor (Company Name) Contracror License No. Master Lic. No. (Plant
� � � �_���i�is�i. � � ��t�
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Mailing Address (Conhacfor or Owner Performing Ir�l Hqn� ' .
'..F.._ w A .
Authorized Signature a or lollafion) l Phone No.
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EB 00001 A-11 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY