P - 80708�7,��-354 e3w
, Home Duplex
Commercial Industri
Air Cond. Htg. Ec
Dryer Range
"X" above the work covered
REQUEST FOR ELECTRICAL INSPECTION -
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
Other: New Addn
51 Farm Remod
uip. Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
by this request. Enter remarks in this space and on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepied without fhe correct fee:
Other Fee # Servi e Entranc ize Fee # Circuits/Feeders Fee
Mobile Home Park Stal) to 00 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 20 Am s Above 100 Amps
Transformer/Generator INSPECTOR•s usE oN�Y TO�I �
Sign/Outline Ltg. Xfmr. J �
Alarm/Remote Conhol
Swimming Pool
I here certi that I ins the eleclrical insfallafion deuribed herein on the dafes stated
Irriqation Boom a,,,�,�„ ��e
� Investigative �e � '` fi • � � ���. � �—��'�" �����
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHI 18 MONTHS.
OFFICE USE ONLY This request void I S monihs from validation date printed in this box.
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PLEASE PRINT OR TYPE
Requesf Dafe/ ] � Rough-in inspecfion required? ❑ Yes o Inspection Other lhan RougMn: Reody Now ❑ Will Call
5" 25 /� (You must call fhe inspeclor when �eady) Dafe Ready:
I, �licensed contractor ❑ owner hereby request inspecfion of the above elechical work at
Iob Address �Sheet, Box, or Roufe,No.) Ciy Zip Code
5'1 s � �v �s �,�d���
Saction No. Townshio Name or o. Ranae No. Fire No. Couny
�l'P�!' E S �O�S ��ele
upplier Address
N� s. P 31ts
I Conhacfor (Co�e)
� � C�.�C'-ei72�c ; � Nc ,
Address (Contractor or Owner Perfo g Ins afion)
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ed Signature Conha r or Owner PerForming Installafion)
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Phone No.
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��-�t/%�,°E' /�oirli� �6e'
nhactor License No. Master Lic. No. (Plant Elect. Only�
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1 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY