P - 84340r REQUEST FOR ELECTRICAL INSPECTION ��.
r`-1� `F V- 3 5 3� 1n821 Univers ty Ave. r Rm. S-128, tSt. Paul, MN 55104
Phone (612) 642-0800 '�'
Home Duplex Apt. Bldg. Other: New Addn
Commercial Ind trial Farm Remod
Air Cond. tg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above ihe work covered by this requesi. Enter remarks in this space and on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted withoui the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps �
Street Ltg./Trar`fic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
I hereb certi fhat 1 ins Ied the electrical installation described herein on the dates stated
Irrigation Boo � Rough-In Date
Special Inspection
Investigative Fee F�nal - �' Da�e��� �r�
� �---.. ��._ .
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONIY This request void 18 months from validation date printed in this box.
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IIIIIIIIIIIIIIIIIIIIIII�IIIIIIIIIIIII �,�
* � 4 4 6 3 5 3 5* PLEASE PRINT OR TYPE
ReqyEst Date� `� � Rou h-in ins ecfion re uired? ❑ Yes
g p q ❑ No Inspection Other Than Rough-In: eady Now 0 Will Call
�'� �You must call fhe inspecfor when ready) Date Ready:
I, icensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address �Sheet, Box, Roufe No.) City � Zip Code
� � � t �� - 5.� 32�
Secfion No. Township Name or No. Ronge No. Fire o. Coun _ /�
Occupan Q
Power Su�oli
Confractor
0
Mailing Address,(Conhacfor or
Phone No.
Confractor License No. I Masfer Lit.
(Contractor or Owne P orming Insfallafion) / Phone No.
� �� � �i'� �`7�
STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY