P - 839305.3�.=693 ��
Home Duplex
Commercial Industrial
Air Cond. Htg. Eqd
Dryer Range
"X" above the work covered 6
l
REGIUEST FOR ELECTRICAL INSPECTION =-� �
Minnesota State Board of Electricity I�
1821 Universiry Ave., Rm. S-128, St. Paul, MN 55104 I
Phone(612) 642-0800 I
. Other: New Addn I
farm
Water Htr. L
Elec. Heat T
request. Enter rem
Mgmt. Other:
$ervice
in this space and on ihe back of the white copy
Calculate Inspection Fee - This Inspection Request will not be accepied wifhout the correct fee:
Other Fee # ervice Entrance Size Fee # Circuits/Feeders
Mobile Home Park Stall � 0 to 200 Amps 0 to 100 Amps
Sfreet Ltg./Traffic Sig. Above 200 Am s Above 100 A�
Transformer/Generator INSPECTOR'S USE ONLY TOT,
Sign/Oudine ltg. Xfmr.
Alarm/Remote Control
Swimming Pool ��- �q�i�.be�
I hereb certi ihaf I ins ihe i ms II fion e i h on"i6e at!
Irrigation Boom RoogM� �
Special Insp ��° ""
F�
Final Dale
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This requesf void 18 months (rom validafi n date printed in is box.
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( IIII II II) I) III II III II III II I II II) II III I(III I ��
* � 5 3 1 6 9 3 ��K PLEASE PRINT OR TYPE J'
Requesf Date Rou h-in ins tion r uired? es
g pec eq ❑ No Inspecfion Ofher Than RougMn: ❑ Ready Now ❑ Will Call
�You must call the inspector when ready� Date Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job A dress S�t, Box, or Route No.) ` Ciy � %/ Zip C����
.; � a�� � �r�P s
Section No. Township Name or No. Range No. Fire No. Coun /� �
occo r
���
Power Supplier
tV'�J°.
Address (Contracror or Owner
� / / i/ (N I iG,
I `���/"r/ /
Phone No.
�3� � � �. 7��- S'lU �,�
MU
Confrador License No. Master Lic. No. (Pla�
� C1.,4�'lf��� /9'��U�
�-n � �%�' `�s`�3
�n� Phone No.
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3EE INSTRUCTIONS ON BACK OF YELLOW COPY