P - 80250� REQUEST FOR ELECTRICAL INSPECTION
.� (� � o`� Q� � Minnesota State Board of Electricity
`~� -� �� 1821 University Ave., Rm. S-128, St. Paul, MN 55104 =
Phone (612) 642- 800 '�'
Home Duplex Apt. Bldg. Other � �-w New Addn
Commercial Industrial Farm ` b�� �� Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
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Calculate Inspeciion Fee - This Inspection Request will not be accepted without fhe correci fee:
Other Fee # Service Entrance Size Fee # Circuits/Feed�
Mobile Home Park Stall 0 to 200 Amps _ "° 0 to 100 Amps
Sfreet Ltg./Traffic Sig. Above 200 Am s Above 100
Transformer/Generator INSPECTOR�s use oN�v Z(
Swimmi
Fee
�.Sa
that I ins the elechic installation described herein on ihe dates slated
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Investigative Fee '^ "-�3 l —Q�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
� OFFICE USE ONLY This request void 18 months 6om validation date prinfed in fhis box.
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PLEASE PRINT OR TYPE
Request Date Rou h-in ins on r uired? Yes ❑ R Now �II Call
(g pecfi eq ❑ No Inspecfion Olher Than RougMn: eady
� 3"� ►�� (You must call the inspector when ready� Date Rendy:
I, ❑ licensed contractor �, owner hereby request inspection of the above electrical work at:
1ob Address (Sheet, Box, or Route No.) Ciy Zip Code
�5�9 I�cCn�wlc Av� �L I—C1��C 7/ .ls'[3 �
$ecTion No. Township Name or No. Range No. Fire No. Coun
3 a -� y �.,�k �
occop� r
Yc�cr ��Sa/�
Power $upplier /
NSP
Elechical Conhacror �Company Name�
�wncr
Mailing Address (Conhactor or Owner Performing Insfallation)
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Phone No.
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o. Master Lic. No. (Nanf Elecf. (
Authorized Signafur hacror or Owner Performing Insfallafion) •' i � Phone No.
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EBO0001 A-1 1 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY