P - 83427REQUEST FOR ELECTRICAL INSPECTION �
7 n�` O Q� � Minnesota State Board of Electricity
l.l V� � 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. Enier remarks in this space and on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fe J.� �
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Anps
Transformer/Generator INSPECTOR'S USE ONLY TOTA�
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control �-�,�
Swimming Pool
I hereb certi that I ins the elechical installation described herein on the dates sfated
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Special Inspection � � � 6 � �
Final � Dofe
Investigative Fee /� Zo-�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
_ OFFICE USE ONLY This request void I S months from validation date printed in this box.
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PLEASE PRINT OR TYPE
Requesf Date Rough-in inspection required$ ❑ Yes y No Inspecfion Olher Than Rough-In: ❑ Ready Now Will Call
i! !��g � (You musf call the inspecfor when ready� � Date Reody:
I, � licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address �Sheet, Box, or Roufe No.) Ciy Zip Code
9 - �� ►-,�1'�
Seclion No. Towns ip Name or No. Range No. Fire No. County
�4H o k�
Occupant Phone No.
r►? oo�-e �,�e f �s
Power $upplier Address
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Electrical Conhacfor �Company Name� . Contracfor�License No. Master Lic. No. (Plant Elecf. Only)
/2 TSEt,E� r�e i C C,�►n iy 89
Mailing Address (Contracior or Owner Per(orming Installation)
87a0 -o2S7 � v�N w !'�'In . 33'3 9d'
Aufhorized $ignature �Conhactor or Owner Performing Insfallafion� . Phone No.
�.� . �y/-9azo
E OOIA-1 1 8/96 S E BO D COPY - SEE INSTRUCiIONS ON BACK OF VELLOW COPY