P - 78646REGIUEST FOR ELECTRICAL INSPECTION
8 0') �� Q Q Minnesota State Board of Electricity
,�► L �� V � 1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800 ` '
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm — �%� /�/�G L(/ Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Ronge Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
Calculate Inspection Fee - This Inspeciion Requesf will not be accepted wi►hout the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall to 200 Amps 0 to 100 Amps
Street Ltg./Troffic Sig. Above 200 Am s Above 100 A s
Transformer/Generator INSPECTOR'S USE ONLY T
r
Sign/Oudine Ltg. Xfmr.
Alarm/Remote Control 6
�
Swimming Pool
I her �a � fhe eledrical insfallation described herein on fhe daf
Irrigafion Boom RougMn Da�
Speciallnspection '�"` '�
Final ' Da ;^ � �-�
Investigative Fee — �
THIS INSTALLATION MAY BE ORDERED DISC _ CTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This roquesf wid monlhs 6om validation date printed in this box.
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PLEASE PRINT OR TYPE T/' ��/
Requesf Dafe Rough-io inspecfion requiredZ es ❑ No Inspecfion Ofher Than RougMn: ❑ Ready Now �❑ Will Call .
�You must call the inspector when ready) Date Ready:
I, ❑ licensed conhactor �owner hereby request inspection of the above electrical work at:
Job Address �Street, Box, or Route No.) City � Zip Code
Secfion No. Towns Name or No. R�e No. Fire No. Couny
3 �3 z_ �
Occupanf Phone No.
w� �� vo� 7 - 7��- 6 a 3
Power Supp�sn� � Address
y
Eleckiml Co�hacror (Company Name) Contracror license No. Moster Lic. No. (Plant Eled. Onl�
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Mailing Address fConhacfor or Owner Performing Insfallation�
S hc�"'�'f v'� !/-` ST �l/
Authorized Signature (Conkacror or Owner PerForming Installafion� Phone No.
EB00001A- 1 8/96 TATE BO D COPY - EE INSTRUCTIONS ON BACK OF YELLOW COPY