P - 77862RE(aUEST FOR ELECTRICAL INSPECTION �`� es-0000,-oa
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K�,. O 3 9 2 See instrudions for completing this iorm on back of yellow copy. �
'X" Below Work Covered by This Request '�.� �
e'Add Rep. TypeofBuilding AppliancesWired EquipmentWired
Home Range Temporary Service
Duplex Water Heater Electric Heating
Apt. Building Dryer Other (Specify)
Comm./Industrial Furnace
Farm Air Conditioner )
Other (speciry) Contractor's Remarks: �
Compute /nspection Fee Below:
# Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Swimming Pool 0 to 200 Amps 0 to t00 Amps
Transformers Above 200 Amps Above 100 Amps
SignS Inspector§ Use Only: TOTAL
Irrigation Booms r � �"`�� ^ /�, �
Special Inspection
Alarm/Communication TNIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT
Other Fee COMPLETED WITHIN 18 MONTHS.
I, the Electrical Inspector, hereby Ro����` �• _ �ace �-
certify that the above inspection has F��ai `� �� �( 3 �
�°.-""� Date
been made. � .,- C �'—�----�•-�� �. -�:�'ric�
OFFICE USE �NLY � � ►�, � j
This request void 18 months from f 1
K10392 � � � -
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Request Date Fire No. Rough-in Inspection J
�+ 9_ 9 Required? ❑ Ready Now ,CI Will Notify Inspector
O Yes No l When Ready?
I❑ licensed contractor �owner hereby request inspection of above electrical work at:
Job Address (Street. Box or ute No.) Ciry
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Sedion No. Township Name or N Range No. Counry
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OccupantlP IN � , / Phone No. /'
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Power Supplier Address � ��
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Eiectrical Contractor �Comp y Name� Contractork License No.
Mailing Adtlress IContraciq�.pr Owner Making Installation)
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Authorized Signatwe IContractoriOwner Making Installation)
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MINNESOTA STATE BOARD OF ELECTHICITY
Grigys-Midway Bldg. — Room 5173
1821 University Ave., St. Paul. MN 55104
Phone (612) 642-0800
Phone Number
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ENCLOSED.