P - 82471��J2°230 �
Home Duplex
Commercio( Industrial
Air Cond. Htq. Equi
"X" above the work covered by
RE(IUEST FOFE ELECTRICAL INSPECTION
Minnesota State Board of Electricin� �
1821 University Ave., Rm. S-128, St. Paul, MN 55104 _
Phone(612)642-0800 "�'
Other: New Addn
farm
Water Htr. Load Mgmt. Othef :
Elec. Heat Temp. Service /� �O
request. Enter remarks in this space and on
copy
Calculate Inspection Fee - This Inspection Requesf will r,ot be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Ar
Transformer/Generator INSPECTOR'S USE ONLY TOT�
Sign/Outline Ltg. Xfmr. ��{y..�e' �
Alarm/Remote Control
Swimming Pool
I hereb ceAi that I ins the elechiml installafion described herein on the dat�
Irriqation Boom . ; o..,,..�,.i.. �- n..b
Fee
Special Inspection �- � V —`�G
Final D
Investigative Fee ��—'Zd�Cr%1
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 monihs from validation date printed in fhis iwx.
iioiliiilliiisliiiiililiiilliii�in�im� ��:�� � �
* 0 8 0 2 2 3 0 3* �(�(9 a��� �
� PLEASE PRINT OR TYPE
Request Date Rou Irin ins tion r uired$ Yes
g pec eq _❑ No Inspec�ion Other Than RougMn: ❑ Ready Now ill Call
pcT �o, ao�o n'ou must call the inspector when ready) Date Ready:
I, ❑ licensed confractor ]aowner hereby request inspection of ihe above electrical work at:
Job Address (Sheet, Box, or Rouffi No.� City Zip Code
(73�i l���A-s7aN D2 �iI�G�Y �s4�3a-
$ection No. Township Na�r�prDNo. Ra� � Fire No. Couny ��
_,...1 � ��
Occupant ��L ��� — Phone No. _� � '���a
(V 3 °
Power Supplier���
Elechical Conhactor �Company
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Mailing Add ss nhacfor or
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2 Conkaclor License
8 � �.
Performing InsTallahon)
A i ,
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Aufhorized Signatur onk o rFo ' Inslallafion) Phone No.
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B-OOOOlA-11 8 96 S7p7E gOAR COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY