P - 84567/1 REf�UEST FOR ELECTRICAL INSPECTION w�..
�4 7 L= � 5 2 8 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" a6ove 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 Inspec►ion Request will not be accepted without ihe correct fee:
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 Amps
Transformer/Generotor INSPECTOR�s usE oN�v TOTAL /�
Sign/Outline Ltg. Xfmr.
Alarm/Remote Conirol
Swimming Pool
Irriqation Boom
that I ins ected the electrical insfallafion dexribed herein on the dates stated
Date
Investigative Fee "� V � """' �_��.��, ___,�_ �. � jC� �
! THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This request void 18 months 6om validafion date printed in this box.
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* � 4 7 4 5 2 8 7�k PLEASE PRINT OR TYPE ��
Requesf �/ � Rough-in inspecfion required? ❑ Yes
❑ No Inspection Olher Than RougMn: eady Now � Will Call
(You musf call the inspector when ready� Dafe Ready:
I, censed contractor ❑ owner hereby request inspection of the above electrical work at:
)o Addreu (Sfreet, Box, or Route No.) Cih. Z�P C�
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Secfion No. Township e or No. Range No. Fire o. County A �
Occupant � � w
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Power Supplier�� Address
ical Conhaclor � mpa� Name)
G12,n�,� l� �I� r �
Nlaili� dreu �Conhactor or Ow� Installafi`�
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4uthorizad�Si�rI�lOFelQonkoctor or Owner Pe yinil�� Installafionl
Phone No.
No.
BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY
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