P - 81657�C2-243 �
Home Duplex
Commercial Industrial
Air Cond. Htq. Equi
"X" above the work
REQUEST FOR ELECTRICAL INSPECTION p
Minnesota State Board of Electricity 3
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �`:
Phone {612) 642-0800 ''�"
Other: ,Q �, � New Addn
Farm �U .S-Ls
Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
request. Enter remarks in this space and on the
the wl�ite copy only.
Calculate Inspection Fee - This Inspection Request will no� be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders
Mobile Home Park Stall 0 to 00 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Ai
Transformer/Generator INSPEC`TOR's usE po_N���y ��� TOT
Sign/Oudine Ltg. Xfmr. /`� � f St� �
` ��. y�,
Alarm/Remote Conhol � � /�� �,� � ��/f' �� �
Swimming Pool'
���
I hereb ceAi that I ins ted the elechical installation de ribed herein on the dah
Irriaation Booml� n A � D......ti l.. E�"'1 � n...�,
Fee
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Investigative Fee �3" Z
THIS INSTALLATION MAY BE ORDERED DISCONNE D IF NOT COMPLETED WITHIN 18 MONTHS.
OFF7CE USE ONLY This requesf void 18 months kom validation dafe prinfe�i�in fhis box.
I I��I �I III �I �II II III II III II III�I (II ( y�.
� I�� �i+ 5� �
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PLEASE PRINT OR TYPE
Request Dale Rough-in inspeclion required8 �Yes ❑ No Inspecfion Ofher Than Rough-In: y
' r ❑ Read Now Will Call
� ��� O� (You must call fhe inspeclor when ready� Date Ready:
I, ❑ licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address �Sheet, Box, or Roufe No.� City Zip Code
5�1 �a��'w�+an-F St NE �Yidle S�'t3a
Section No. Township Name or No. Ranpe No. Fire No, County
I 30
Occu nt
�Grc� I�1nC 11%K�t
Power Supplier
�xc�ll ����
Elechical Contracror (Company Name)
OwN ER
Mailing Address �Conhacfor or Owner Performi
Shrv� E
Authorized SiB,ature (Conhacfor or Owner Perl
// . � �
a �c
Mo1s
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Pho No.
�'763� 7� �l'? ( �(d
j�,,}h 1%i.tis�Or�
mhactor license No. Masterlic. No. �Plant E
STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY
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