P - 84053����IIII IIII) III�I IIIII IIIII IIIII IIII) IIII IIII
*03716305*
Home Duplex AF
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
Other: New
Commercial Industrial Farm Remod
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.
SAVER'S SWITCH INSTALLATION
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Addn
Repair
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stail 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200_Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Outline Ltg. Xfmr. 15. 50
Alarm/Remote Control
Swimming Pool (< '" Y i• 3 hereby certify that I inspected the electrical installation described herein on the dates stated
Irrigation Boom J ough-In Date
Special Inspection
Final � D �"/ �1�
Investigative Fee 7�r /
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.
371-630 � � � !�, � a, s 73 a,
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JOB HUMBER �9706000
PLEASE PRINT OR TYPE
Requerst�at�1,7 / 9,7 Rough-in inspection required? ❑ Yes f'L plo Inspection Other Than Rough-In: p, Ready Now ❑ Will Call
1 / �L �C
(You must call the inspector when ready) Date Ready:
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I, �] licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Street, Box, or Route No.) City Zip Code
05811 HACKMANN AVE NE FRIDLEY 55432
Section No. Township Name or No. Range No. Fire No. County
Occupant
Power Supplier
Contractor (Company Name)
Address
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8/95 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF
Phone No.
�%i-�a%i
. Master Lic. No. (Plant Elect. Only)
Phone No.