P - 80258�1"�-365 �
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"X" above the work
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �i
Phone (612) 642-0800 ��'
Other: New Addn
�I Farm
uip. Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
by this request. Enter remarks in this space and on
copy
Calculaie Inspection Fee - This Inspeciion Request will not be accepted wiihout ihe correcf fee:
Other Fee # Service Entrance ' e Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
TransformerjGeneraior INSPECTOR'S USE ONLY TOTAL
Sign/Outline Ltg. Xfmr. (' �l g, 28- oo_ �� S-�
Alarm/Remote Conirol � � i'����`f"�`R� S^ -L3 __o.st>
Swimming Pool d/��° 'e�, � ��—et7
I hereb certi that I ins the elechica ' tallafion e i ere on e d s s
Irrigation Boom RougMn ' � Dar�
Special Inspect't 6�' 3�� 0
Final
Investigative Fee + ��d
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMP�ETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validation date printed in this box.
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PLEASE PRINT OR TYPE r
Request Dafe : Rou h-in ins lion re uired? �Yes
9 P� 9 ❑ No Inspecfion Other Than RougMn: ❑ Ready Now Will Call
`"� �s� �/ �You musf call the inspector when ready) Date Ready:
I, �licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Skcet, Box, or Route No.) Ciy Zip Code
7�l-lZ Loh� e�°7'o C'urV� I�lF �i��� �5�3
Section No. Township Name or No. Range No. Fire No. County
��O oi'� O�Q
Occupant Phone No.
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Power Supplier Address �
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Elechical Confrador (Company Name) Conhacfor License No. Master Lic. No. �Planf Elecf. Only)
BFL e�-f��rC �f' �.S'�t c��/ G�4 ��� 3
Mailing Addren (Contracfor or Owner Performing Installation� �� �
��S Q� c,la �� Cr'r ��oc� SG 30/
Aufhoriz Signafure (Conh r or er PerForm' g In Ila Phone No. �.p�
� ����' �70 Q
&00001 A-11 8/96 STATE BOARD COPY - SEE INSTRUCiIONS ON BACK OF YELLOW COPY