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P - 82063, REQUEST FOR ELECTRICAL INSPECTION �� �v��.J - 9 9 2� Minnesota State Board of Electricity � J � r 1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993 -. (651) 642-0800 www.e�ectricity.state.mn.us a'�'' Calculate Inspection Fee - This Inspeciion Request will not be accepted without the correct fee: Other Installations fee # Service Enirance Size Fee # Circuifs / Feeders Fee Mobile Home Park Stall 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. ��• � ''�� I hereb certi that I Boom Rouah-In described herein on the dates stafed: Dafe r � � Investigative Fee � � ( �� - � T� `v `� `"'I THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS. OFFICE USE ONLY This requestvoid 18 months from validafion dafe prinfed in this box. f1���111�11�1�1111iNll��il�f � • ��. � * 0 9 1 3 9 9 2 4* aJ�`7` e PLEASE PRINT OR TYPE Requesf D� �� rO�` Rough-in inspecfion required? ❑ Yes No � Inspection Ofher Than Rough-In: Ready Now � Will Call � You must call fhe inspector when ready Date Ready: I,,�censed contractor ❑ company ❑ owner hereby request inspection of the above electricaf work at: Job Address (Street, Box, or oute No.� Zip Code � �� _ Secfion No. Township Name or No. Range No. Occu M� �- � �Power Supplier Address lecfri � Conhacfor / Company Nome _� � Mailin Ad res ( onhactor, C mpany o� Owner Performin Inslallafion) �U �1 � �G�;-� ��V Author' afure (Confmctor, Company or Ow er Performing Insfallai =6-000 1 2 5/1999 . STATE BOARD COPY � � � � � I Phon� No. — � � � lo � - a � Confractor License No. Master Lic. No. (Planf Elect. On G.�i'O (� � � � Phone Number � � ZG SEE INSTRl1CT1nNS ON RACK OF VELL [1W