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Home Duplex
Com merc i a l I n d ustri a l
Air Conditioner Htg. Equip.
Dryer Range
"X" above the work covere
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Calculate Inspecti
Other Installations F
Mobile Home Park Sfiall
Street Ltg. / Traffic Sig.
Tra nsformer/Generator
Sign / Outline Ltg. Xfmr.
Alarm/Remote Conhol
Swimming Pool
Irriqation Boom
REQUEST FOR ELECTRICAL INSPECTION =
Minnesota State Board of Electricity
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993 -
(651) 642-0800 www.electricity.state.mn.us "�'
Repair
Water Hfr. Load Mgmt. Other:
Elec. Heat Temp. Service
d by ihis request. Enter remarks in this space and on the back of the white copy only.
Sc,�{ f71. ��' Ccc-�12. T'� Co -
-�D tr �( i CO n�'le. � d(1
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on Fee - This Inspection Request will not be accepted without the correct fee:
ee # Service Entrance Size fee # Circui/s / Feeders Fee
0 to 200 Amps 0 to 100 Amps
Above 200 Amps Above 100 Amps
INSPECTOR'S USE ONLY TOTA� � $p
2�843
it 1 insoected the elechiml installation described
oare
' ' Final % �a �
Investigative Fee � ' Z �'� �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validation date printed in this box.
I�����1��lil�l���Ili� III�� ��� �e�-��
1� �l�l� �
* 0 8 9 9 3�8 2 6* � �"�8���
PLEASE PRINT OR TYPE
Requesi Date Rough-in inspecfion required? �❑ Yes ❑ No Inspection Other Than Rough-In: Ready Now � Will Call
2�- I�,,, Q� You must call the inspecfor when ready Date Ready:
b/
1, �licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address �Sfreet, Box, or Roufe No.) Ciry� � Zip Code
�:�0 1 F �.v-t.c.� %�_ � �'�' �a� 'c�
i No. I Township Name or No. � . I Range
ant
1 � ��
iupplie� Addre:
S
:al Confractor / Company Name .
�1 �bt�d �1� t �
3 Address �Contracror, Company or Owner Pedorming Instalb
.��� �� .h � c�ci `. :i..
ized�Signa�yre (Confractor, Company or Owner Performing Ir
/ ��
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D1A-12 5/1999 STATE BOARD COPY
Phone No.
Elect.
SEE INSTRUCTIONS ON BACK OF YELLOW COPY