P - 83458REQUEST FOR ELECTRICAL INSPECTION ��
7 O.IJ - 4 6 2� Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800 '�'
i�
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re air
Air 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 s ace and on ihe back of the white copy only.
GcJ t� 2�i �J6L-N ✓� e �, �- �
Calculate Inspection Fee - This Inspection Request will nof be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Sheet Lfg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR�s use oN�Y TOTA��"S
Sign/Oudine Ltg. Xfmr. � �
Alarm/Remote Conhol
$wimming Pool
I hereb certi that I ins ected the electrical installation described herein on the dates sfafed
Iff19OhOf1 BOO Rough-In Date
Speciaf Insp
Find Date _ �.
Imestigative Fee —/
THIS INSTALlAT10N MAY BE ORDERED DISCO CTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 1 S months from validation dafe printed in this box.
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* 0? 0 0 4 6 2 5* $�JrU
PLEASE PRINT OR TYPE
Requesf Date � Rough-in inspecfion required? ❑ Yes o Inspecfion Ofher Than RougMn: eady Now ❑ Will Call
'� 3 (You must call the inspector when ready� Date Ready:
I, �censed contractor ❑ owner hereby request inspection of the above electrical work at:
1ob Address (Sfreet, Box, or Route No.� City Zip Code
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Seciion No. Township Name or No. Range No. Fire No. County
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Occupanf � Phone No.
PrLt�N DL Sa�,
il Conkaclor �Company Name� Conhacfor License No. Ivlaster Lic. No. (Plant Elecl. O
N n2k's � L�ca�,,� c r� o� �7 4
Addreu (Conhacfor or Owner Performing Insfallafion)
3 � a�Y D� � � � �n�
:ed Signature acfor or Owner Performing Insfollafion) . Phone No.
� - z� �37 ��
lA- /96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY