P - 82124Y�
(�-901-287 �
Home Duplex
C o m m erc i a l I n d u str i a l
Air Conditioner Htg. Equip.
Dryer Range
"X" above the work covered by
�`-/� 11/C'E
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1827 Universiry Avenue Suite S-128, Saint Paul, Minnesota 55104-2993
(651) 642-0800 www.electricity.state.mn.us
Apt.
Water Hfr. Load Mgmt.
Elec. Heat Temp. Service
is request. Enter remarks in
G�,� ��
space and on the back
copy
Calculate Inspection Fee - This Inspection Request will nof be accepted without the correct fee:
Other Installations Fee # Servic Entrance Size Fee # Circuits / Feeders Fee
Mobile Home Park Stall / 0 to 00 Amps ,$0 • 0 to 100 Amps
SMeet Lfg. / Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign / Outline Ltg. Xfmr, s0 , SO
Alarm/Remote Control
Swimmi
I hereby certify }haf I inspected the elecfrical insfallWion described herein on the da
Rounh-In � Dafe
Addn
Repair
' ' Final // I Dafe�, f >
Investigative Fee � �C..— " t % � "��
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 ONTHS.
OFFICE USE ONLY This request void 18 months from validation dafe prinfed in fhis box.
I��N�Ifl���I�U��I��I��IN�(�I • ���/
* 0 9 0 1 2 8 7 * °Z7�`�
3
PLEASE PRINT OR TYPE
Requesf Date Rough-in inspecfion required? ❑ Yes o Inspection Ofher Than Rough-In: ❑ Ready Now Will Call
/� � y�i — p() You must call the inspector when ready Date Ready:
1, � licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address (Street, Box, or Route No.) Ciry Zip Code
,�/ Z � �Ol1�Zvi�/ ,Ql✓� �lLlOLE SS�ZI
. Section No. Township Name or No. Range No. Fire No. County
Occupant � Phone No.
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Power Supplier Address
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Elechical Contractor / Company Name ��" j�(, �*� Contractor License No. Master Lic. No. �Pfant Elect. Only)
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Mailing Address (Contmctor, Company or Owner Performing Insfallation�
� �' � � � �v � �"`�O �QoS�c�' /� ,�"S//3
Authorized Signoture (Contracror, Company or Owner Performing Installafion) Phone Number
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EB-00001A-12 5/1 STATE BOARD COPY SEE INSTRl1CTIONS AN BACK nF VELI f1W C[1PV