P - 82534r
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1
Home Duplex
Commercial Industri
Air Cond. Hta. Ea
"X" above the work
REGIUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �`
Phone (612) 642-0800
Apt. Bldg. Othu: �-�, New Addn
al Farm l� � Remod Re air
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.
Calculate Inspecfion Fee - This Inspec►ion Request will not be accepfed without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/FeedE
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100
Transformer/Generator INSPeCroR'S USE ONLY � TC
Sign/Oudine Ltg. Xfmr. �c�� L�-� �9'��
Alarm/Remote Control � f- F� � O{��- -�
Swimmin Pool
Fee
J
9 I hereb certi that I ins ected the electrica ' stallafion described herein on the dates staled
Irrigation Boom Rough-In Date
Speciallns z �a
Investigative Fee F4 � � 7�� ��
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLET D WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 monfhs from validation dafe prinled in this box.
IIiIIIIlliiilllllillllilllliii�ll�lil�lli�l �,.5° ,
* 0 8 0 2 2 3 6 0* �����
PLEASE PRINT OR TYPE
Re�je Date Rou fFin ins ion r uired$ Yes
��., g pecf eq ❑ No Inspecfion Other Than RougMn: ❑ Ready Now Will Call
(� I �� (You must call the inspector when ready) Dafe Ready:
��
I, ❑ licensed contractor�owner hereby request inspection of the above electrical work at:
lob Address ( heet, Box, or e No.) Ci Zip Code
��3� ��s� ..�`r� N'� �--� r� .�-,
$ecFion No. Towns�Nome or No. Range No. Fire No. C nty
�
(CompanyNam .^� �
J�
nhacror or Owner Performing Insh
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P�o� �3 �- ��7 �{ ��'-�r
� n�� �. D�u�,Z
No. Master Lic. No. I%anr Elect. OnHI
STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY