P - 81034' RE(�UEST FOR ELECTRICAL INSPECTION :� �
,� ��-� 4 6� 8121eUniversty A earRm. Se128,ISt. Paul, MN 55104
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� � // Phone (612) 642-0800
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Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re air
Air Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by ihis request. Enter remarks in this space and on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Requesi will not be accepted without the correct fee:
Other Fee # Servi e Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Ge�erator INSPECTOR'S USE ONLY TOTAL -1
Sign/Outline Ltg. Xfmr. 1�0 ,� C/
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ted the electrical installation described herein on the dates stated
I�rigation Boom RougMn pure
Speciallnspect' '
Final p � vQ
Investigative Fee O - ��
THIS INSTALLATION MAY BE ORDERED DI D IF NOT COMPLETED WITHIN 18 MONTHS•
OFFICE USE ONIY This roquesf void 18 monihs hom validafion dafe printed in this box.
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PLEASE PRINT OR TYPE
Requesf afe Rough-in inspection required? ❑ Yes �Tlo Inspecfion Other Than Rough-In: eady Now ❑ Will Call
����% �� t �You must call the inspector when ready) Dafe Ready:
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I, � licensed contractor ❑ owner hereby request inspection of the above elecfrical work at:
Job Address (Sheef, Box, or Roufe No.) City Zip Code
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Section No. Township Name or No. Range No. Fire No. Co w �
Occupant � � . j .
N
Power Supplier Address
Elechical Conhacir �Company Name� �
�rs ri� G
Mailing Addy ss (Conhacfor o�Owner Performiny Insfallafion) -
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Phone No.
d/� -.So
Conhacror License No.
igna�ure ��.onnacror or vwner r normmg msraua �
�$� STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COP�
Elect.
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one No.
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