P - 84498REGIUEST FOR ELECTRICAL INSPECTION - -�..
4��- 9 2 5 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 ir
' Cond. tg. Equi . Water Htr. Load Mgmt. Other:
Dryer nge Elec. Heat Temp. Service
"X" above ihe work cover y this request Enter remarks in ihis space and on ihe back of the white copy only.
Calculate Inspection Fee - This Inspection Request will not be
Other Fee # Service Entrance ',
Mobile Home Park Stall to 00 Amp
Street Ltg./Traffic Sig. Above 200 i
Transformer/Generator INSPECTOR'S USE ONLY
Sign/Outline Ltg. Xfmr.
Alarm/Remote Confrol
Swimming Pool
I hereb certi fhat I ins
Irriqation Boom Q,,,,,,�„
without the correct fee:
Fee # Circuits/Feeders
,G 0 to 100 Amps
Above 100 Amp:
TO�AL
r
the eledcical insmllation described
Fee
Special Inspecti Z✓ — � ``'" �
Finol �' D �"
Imestigative f ,3 �-�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE �LY This requesf void 18 monlhs froJy�idation date printed in this box.
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* � 4 � � 9 2 5 4* ASE PRINT OR TYPE
Request Date Rou h-in ins on uired? es
g pecti req ❑ No Inspection 01her Than RougMn: ❑ Ready Now Will Call
�`Q �� 7 �You must call the inspecfor when ready) DaTe Ready:
I, ' ensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address �Sheet, Box,Rr Rou1e No.) City n � Zip Code
Sechon No. I Township Name or No.
Occup
� LJ ���[iv � ! '
Power Supplier
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Electrical Conhacror �Company Name)
�� � r�._
Mailing �f� C�r �� I�
_ . �,3eio
Phone No.
Conhactor License No. � MasTer lic.
"�""""' �'' '" STATE BOARD COPY - SEE INSTRUCTION�ON BACK OF YELLOW COPY
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