P - 83540REQUEST FOR ELECTRICAL INSPECTION �
r�� �- 6 0 7� Minnesota State Board of Electricity � 3
, 1821 University Ave., Rm. S-128, St. Paul, MN 551�4 �:
Phone (612) 642-0800 —1O _ �`'7 _ " '
�r� .r,
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re air
Air C 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 ba k of the white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepied without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile iiome Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL �
Sign/Oudine Ltg. Xfmr.
Alorm/Remote Control
Swimming Poo�
Irriqation Boom
1 hereby certify thof I inspecfed the eleckical installafion described
Rough-In
� Investigative Fee �"� � � � -�j �`�//
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 months from validafion dafe prinfed in ihis box.
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PLE E PRINT OR TYPE
Requesf Da � �� Rough-in inspection required? ❑ Yes o Inspection Other Than Rough-In:
� �You musf call the inspecfor when ready) Date Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Addre� 1.��r, ���r�� C I RCLE �'y F R I DLEY� MN
Secfion No. Township Name or No. Range No. Fire No. County „ �
�
Ready Now ill Call
�"°�°��M I DWEST HEAT I IVG
Power Supplier Add
� f �
Elechirnl Conhacfor (Com ny Name)
h1Il'.—L1�IV ELECTRIC CQ.
Mailing Address (Conkacfot or Owner Performing InsMllation
1�:��8 g�_�siness F�ar��
Aufhoriz�5'rt�R�tme (Conhacfor or Owner PerFor� Installatior
Phone No.
Conkacfor Lice�e,�lp� 1`4� I Master lic. No.
L.H�L�
B1vd�2Er�1'�!"G��IV, MN ci5316
STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY