P - 83804REQUEST FOR ELECTRICAL INSPECTION
4� C7 �- � 0 6 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 ddn
Commercial Industrial Farm Remod Re air
ir Co tg. 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. j
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders
Mobile Home Park Stall 0 to 200 Amps to 100 Amps /
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR�s use oN�v TOT L� ,�}1
Sign/Outline Ltg. Xfmr. /',��
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ted ihe elechical insfallation described herein on fhe dafes siafed
Irrigation Boom Rough-In Date
Special Inspection
Investigative Fe i ti Final � � oa�� _���
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THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 monihs from validation date printed in this box.
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* � 4 6 8 4 � 6 4�c PLEASE PRINT OR TYPE �� �/
Request Date Rou h-in ins ecfion re uired?
R g p q ❑ Yes Inspecfion Other Than Rough-In�ady Now ❑ Will Call
(You must call the inspector when ready) Date Ready:
�icensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job A�ss (Sheei, Box, or Route Ci Zip Code
S�� l�o rJ 2 N��, �7"C v��3o'L
Secfion No. Township Name or No. Range No. Fire No. Coun �"` LY/ � tK/
Occvpant � l n��� Phone No� � �
Z� /
Power Suoolier Ad�l�a«
Elechical Contractor �Company Name) Contractor License �
SpcvcFz �.�ec.�ic�.c caa 1700
Mailing Address (Conhactor or Owner PerForming Installation)
2114 (Ua�h.�.ng�av� S� N.�.
Authorized Signqyre (Gor�rpcfor or Owner PerFormina Insfallation)
Y
STATE
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COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY