P - 84504RE(IUEST FOR ELECTRICAL INSPECTION --
��`y`� �. �� � Minnesota State Board of Electricity
v 1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
Hom� Dup x Apt. Bldg. Other: New Addn
mmercial ., In strial Farm Remod Re air
Air Cond. Htg. Equip. Water Hfr. Load Mgmt. pther:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this requesi. Enter remarks in this space and on the b�ck of the white copy only.
Calculate Inspection Fee - This Insp<
Other Fee
Mobile Home Park $tall
Sheet Ltp./Traffic Siq.
�ign/Outline Lig. Xfmr.
Alarm/Remote Control
Swimming Pool
Irripation Boom
m Request will not be accepted without the correct fee:
# Serv'ce Entrance Size Fee # Circuits/Feeders Fee
00 Amps 0 to 100 Amps
Above 200 Amps Above 100 Amps
INSPECTOR'S USE ONLY TOTAL �
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that I ins ted the electrical insfallation deuribed herein on the daffis sfafed
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Investigative Fee " v � - �`t,,,� __�_____ ' =,3C''-- `
THIS INSTALLATION MAY BE ORDERED DISC CTED IF NOT C0IAPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request wid 18 months from validation date printed in this box.
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* 0�i 4 8 2 3�, 1* PLEASE PRINT OR TYPE
Request Date Rou lrin ins fion r uired? Yes
g pec eq ❑ No Inspec�ion Olher Than RougMn: ❑ Ready Now Will Call
. �You must call fhe �nspecfor when ready� Date Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sheet, Bo�yor Roufe No.) City ` Zip Code
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Seclion No. Township Name or No. Range No. Fire No. Coun �
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Occupgqf . � Phone No.
NV
I ConhqcJp��rqppqy�p�j�, �• �1 Conhacfor License No.
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Address ��Co;hacfor or Owr�r PerFo n�
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or
E&OOOOIA-1 1 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY
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Lic. No.
No.
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