P - 82414� � REQUEST FOR EL�CTRICAL INSPECTION --
` Q � � � � � � � Minnesota State Board of Electricity
v 1821 University Ave., Rm. S-128, St. Paul, MN 55104
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Phone(612)642-0800
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks�t� space an�d o�1� bac� the whi►e copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted without fhe correci fee: �� �(�
Other Fee # Service Entrance Size Pee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps 3,dO
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY T� 3�' �D
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming P I
I hereb certi thaf I in the elechical insfallation dexribed herein on the dotes sMted
Irrigafion B �' RoogMn D
a r d--^�-�
Special Inspection
Final D
Investigative Fee %/ � s.c��
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHI 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validofion date printed in this box.
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PLEASE PRINT OR TYPE
Requesf Dafe J� Rough-in inspection required? ❑ Yes �[lo Inspecf:on Ofher Than RougVrin: ❑ Ready Now Will Call
9�� D(,J (You musf call fhe inspador when ready� Daie Ready:
I, �Jicensed contractor ❑ owner hereby request inspection of the above elecfrical work at:
Job Address (Sheet, Box, or Route .) Ci Zip Code
62$�. I��� Z��. N. �. �'--�1 o L� s� � 3�
Section No. Township Name or No. Range No. Fire No. County
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OccupanVYG�J � �7�xQ V�� 1�� v�V + I V y 9
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Power Supplier O��w� r., Address� ��
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Electrical Confractor (Company Name) Conkacfor License �Noy. Masfer Lic. No. (Planf Elect. Only)
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Mailing Address �Conhacfor or erformi Installafio
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Auth��'Con�r or P rmi nstollaKon) Phone No.
, 763-78�=8�$
E&00001 A-11 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY