P - 79733REQUEST FOFi ELECTRICAL INSPECTION ��°1e
�� � Z e� Q� � � j� Minnesota State Board of Electricity
`� �°� !! /� �� 1821 University Ave., Rm. S-128, St. Paul, MN 55104 �
�f�V � Phone (612) 642-0800 ''�'
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm I� �� � Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. O er: /� ,��_ �/ ,.,
Dryer Range Elec. Heat Temp. Service
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"X" above the work covered by this request. Enier remarks in this space and on ihe back of the white copy only.
Calculate Inspection fee - This inspection Request will not be accepted without the correct lee:
Other Fee # Service Entrance e Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 t 200 mps 0 to 100 Amps
Street Lig./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Ge INSPECTOR'S USE ONLY TOTA� $--o
Sign/Outline Ltg.
Alarm/Remote Control
Swimming Pool
1 hereb certi that 1 ins ted ihe electrical instalfafion dexribed herein on the dates slated
Irrigation Boom Ro� M� Dqe Z
9 ` Z C J
S ecial Inspection
Final _... Dgf�' a Q.�+�
Investigative Fee !P �.�
THIS INSTALlAT10N MAY BE ORDERED DISC NECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void months from validation date prinfed in fhis box.
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PLEASE PRINT OR TYPE
Requesf Date Rou h-in ins tion r uired$ Yes
g pec eq ❑ No Inspecfio� Olher Than RougMn: ❑ Ready Now Will Call
/�„ � O (You must call the inspecfor wh n ready) Date Ready:
I,, ❑ lic nsed conhactor �owner hereby requesi inspection of the above electrical work at:
Job Address (Sheet, Box, or Route No.) Cily Zip Code
7 0� 1 «��Y �� �� ��C� 3f.5-� 3�
Section No. Township Name or No. Range No. Fire No. Couny �
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Occuponf Phone No.
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Power Supplier Address
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Elechical Conhactor (Company Name� Conhactor License No. .Master lic. Na (Planf Efecf. Only)
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Mailing Address �Conhacior or Owner Performing Insfallation)
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Authori SignaNre onfracfor or Owner Perfor i g InsfallaKon) Phone No.
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E&00001 A-11 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY