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REGIUEST FOR ELECTRICAL INSPECTION �°'E
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paut, MN 55104 �;
Phone (612) 642-0800
Apt. Bldg. Other: New Addn
Farm Remod Repair
Air � Ntg. E uip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heai Temp. Service
"X" above the work covered by this request. Enfer remarks in this spoce and on the back of the whiie copy only.
Ca(culate /nspecfion Fee - This Inspection Request wil! not be accepiec! withoui ihe correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stoll 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator iNSPecroR'S USE ONLY TOTAL�O---
Sign/Outline Ltg. Xfmr. �
Alarm/Remote Conhol
$wimming Pool
I herebvi certifv thot I insoected the elechical installation described herein on the dates stated
Investigative Fee r�� {� —��� � � ^^� �
.
THIS lNSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This request void 18 months from validation date printed in this box.
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* 0 7 9 6 3 0 4 4* ��74
PLEASE PRINT OR TYPE
Request Dafe Rough-in inspecfion required$ ❑ Yes �No Inspecfion Ofher Than Rough-In:
6 � 9�� 9 (You musf call the inspector when ready� Dafe Ready: 6.. �
I, �licensed contractor ❑ owner hereby request inspection of the above electrical work at!
lob Addreu (Sheet, Box, or Route No.) Ciy
�3ys-NQ � s S-� : � � �-� � /�
Secfion No. Townshio Name or No. Ranae No. Fire No. Countv
occopaor
3ot (`�n ra� v►
Eleclricol Conhacfor ( pany Namej
/�.T� I��GG:���1
Mailing Address (Conhacror or Owner
S!�-a - �s�
Authorized Signalure (Conhacror or O�
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B-OOOOlA-11 8/96 S7
Conhactor License
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Phone No. � � Z
7�'Y 370�'
Lic.
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Now � Will Call
Installafion)
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ning Ins � Phone No. `! .y
5� �.-9.�
COPY - SEE INSTRUCT10N3 ON BACK OF YELLOW COPY