P - 82765. ° REQUEST FOR ELECTRICAL INSPECTION
v���� 12 Minnesota State Board of Electricity
� 1821 University Ave., Rm. S-128, St. Paul, MN 55104 -
/' Phone (612) 64�-0800 � � ' '
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Commercial
Air Cond.
��X��
Farm
� � Elec. Heat � � T
this request. Enter rem
, S-� s c.
'vlgmt. Other:
Service
in this space and on
New
Remod
copy only.
Calculate Inspection Fee - This Inspecfion Requesf will nof be accepted wiihout the correct fee:
" Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Sfreet Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL (
Sign/Outline Ltg. Xfmr. �� �� � n �/ J�
�.���
Alarm/Remote Control �
Swimming Pool � �,..�
I here cerli that I ins the elechical installafion described� on riTefr sta�ed
Irriaation Boom o,..,,.i.,.. _ � b �, c.
Imestigative Fee " �� Q• �
THIS INSTALLATION MAY BE ORDERED DISCONNE D IF NOT COMPLETED THIN 18 MONTHS.
OFFICE t�E ONLY ihis roquesf wid 18 monihs from validafion date printed in this box.
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* 0 5 3 2 5 1 2 1* �� �
PLEASE PRINT OR TYPE
Requesf Dafe Ro h-in ins on uired? ❑ Yes
ug pecli req ❑ No Inspec�ion Other Than RougMn: ❑ ReadyNow ❑ WiH Call
�--��� � a (You must call Ilie inspector when ready) Date Ready:
I, ❑ licensed conhacror�'owner hereby request inspection of the above elecirical work at:
Job Address �Sheet, Bwc, w Roufe No.) Ciy Zip Code
1 �f � G � � rc..i � cc� �d. IN � � � : �,1 � S �f �.
Secfion No. Township Name or No. Range No. Fire No. Coun
1't �� t�— \, ,
Occupanf Phone No.
�,� � r3��-d.�. R� ��� c.,.�� �e. �� a- —5-� �-3 � 6 Z.
Power Supplier � n q�� � �
r LS �
Elechical Contracpor C�y Name) „ ConhacFOr Licenae No. Masfer Lic. No. (Planf Elect. Only�
N�i�
Maili�g Address (Conhac�or performing Installation)
� ��
Authorized Signature �Con cfw r e Ins �� � Phone No. �� /
_ e.? �� �- �� b �
BO0001 A-11 8/96 gTATE-�` "'^t'.OPY - SEE INSTRUCTIONS ON BACK OF YELLO W COPY