P - 80663RE(�UEST FOR ELECTRICAL INSPECTION
V FJ 1- 2 5 3� Minnesota State Board of Electricity
, 1821 University Ave., Rm. S-128, St. Paul, MN 55104
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 in this space and on the back of the white copy cnly.
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Calculate Inspection Fee - This Inspection Request will not be accepted wifhout the correct fee:
Other Fee # Service Entrance Size Fee # Circuits
Mobile Home Park Stall 0 to 200 Amps 0 to 100 A
Sfreet Ltg./Traffic Sig. Above 200 Am s Above 100
Transformer/Generator INSPECTOR'S USE ONLV
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control N�. �"2 - � � �
Swimming Pool
__ I herebvi certiH that I insoected the electrical installation described herein
Fee
. J�
Invesiigative Fee i '
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFiCE USE ONLY This requesf void 18 months from validation date printed in this box.
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PLEASE PRINT OR TYPE
Request te Rough-in inspecfion required8 ❑ Yes �flo Inspecfion Other Than Rough-In: Ready Now ❑ Will Call
(You must call the inspedor when ready� Da�e Ready:
I; '�,licensed contractor ❑ owner hereby request inspection of the above electrical work at:
lob Address (Sheef, Box, or Roufe No.) City Zip Code
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or No. � Range
Occupant
al �O.t�� �1L' Yl 'S!i{n
Power Supp�ier
:for (Company Name) C�
,1 °�tr .�. � �c.�i-r � c— �
(Confracfor or Owner Performing Installafion)
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�ture �ConkaMor or Owner Performin Installafion)
�` G't
Phone No.
57�' �1 %
ense No. Master Lic.
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�a.,ti.,, _ ° • C-�� -�:. � % �j � I , ,.� $ !
OOIA-11 8/96 �p� gppRD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY