P - 820598ez-191 �
Commercial I I Industrial
"X" ubove the work covE
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REQUEST FOR ELECTRICAL INSPECTION �
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �:
Phone (612) 642-OS
Apt. Bldg. Other: New Addn
Farm �TT Remod air
Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
request. E er remarks in this space and on the back of the white copy only.
S� L���o�
Calculate Inspection Fee - Tl�is Inspection Request will not be accepted without the correct fee:
Other Fee # Serv' ntrance ' e Fee # Circuits/Feeders Fee
Mobile Home Park Stall o�00 mps , 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
t�.,,,in��d�„o i+., xFm. �r.�
Alarm/Remote Conhol
Swimminq Pool
that I inspected the electrical installafion dexribed herein on the dates slated
Dare
Special Ins�tiln� �
Investigative Fee F`� �_ D _� _ �
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.
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P EASE PRINT OR TYPE
RequBSt Date Rough-in inspection required? Yes No InspecKon Olher Than Rough-In: ❑ Ready Now ❑ Will Ca�l
+/ � b� (You must call the inspector when ready� Date Ready:
I, ❑ licensed contractor ❑ owner hereby request inspection of the above elechical work at:
Job Addreu �Sheet, Box, or Roufe No.� Cily Zip Code
/ �U �CA�iE%� ��^�E r���cE
Section No. Township Name or No. Range� jNo. Fire No. County
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Power Supplier
/vs�'
Elech icol Conhactor
Mailing Address (Conhacfor or Owner
or
�LPhone No.
�c� i2 5 �—iI7�S
Address
n�N�A/�G�-� S n%on7N �r �i5 a
�^� Conhactor License No. Master Lic. No. (Plant
/`J
xming Insfallation�
Performing Installation) Phone No.
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:-�OARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY