P - 80346U�899-324 �
Home Duplex Apt.
Commercial Indusirial Farm
Air Conditioner Htg. Equip. Wafe
REQUEST FOR ELECTRICAL WSPECTION ��
Minnesota State Board of Electricity �
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993 ����
(651) 642-0800 www.electricity.state.mn.us '��•
Other: New Addn
Remod Repair
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 only
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Calculate Inspection Fee - This Inspection Requesf will not be accepted wi►hout the correct fee:
Other Insfallations Fee # Service Enhance Size Fee # Circuits / Feeders
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg. / Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
I
Irripation Boom ,
Fee
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that I insoected the elechical installation described herein on the dates stafed:
Investigative Fee r�oa � ��L I ua����.� I
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
� - OFFICE USE ONLY This request void 18 months 6om validafion daM printed in this box.
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* 0 8 9 9 3'2 4 8 � �7�-�
PLEASE PRINT OR TYPE
Re uest Dale Rough-in inspecfion required? ❑ Yes ❑ No Inspection Other Than Rough-In: Ready Now ❑ Will Call
��,�., . O You musf call fhe inspector when ready Dafe Ready: �
I, �icensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sheef, Box, or Route No.� Ciy - Zip Code
�Z � �U �., v� L
Section No. Township Name o. Range No. Fire No. nty
1�-� /G �
Mailing
� ' ,"ri � Phone No.
�/%1C. �%�rIY-I`�C..lV
ipplier Address
Contracfor / Compan Name , Con}ractor License No.
; �c� I � a a
�ddress �Conhacfor, Company or Owner Performing Installafion) _ �
0
� or
Master Lic. No.
STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY