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.
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* 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. — � �
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Confractor License No. Master Lic. No. (Planf Elect. On
G.�i'O (�
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� Phone Number
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SEE INSTRl1CT1nNS ON RACK OF VELL [1W