P - 77200� RE(k�EST FOR ELECTRICAL INSPECTION
/� /� ��, Ci C� Minnesota State Board of Electricify
�t �r J U 1821 Universiry Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
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Commercial Indusirial Farm Remod
Air Cond. Htg. Equip. Water Hfr. Load Mgmt. plher.
Dryer Range Elec. Heat Temp. Service
"X" above the work covered ►his request. Enter remarks in ►his space and on'the back of the whiFe copy only.
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Calculafe Inspection Fee - This Inspection Request will nof be accepted without fhe correcf 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 Amps � Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL S
$ign/Outline Ltg. Xfmr. �/�}� / ���� � ��' �
Alarm/Remote Conhol 1 �
Swimming P �-�- �-3�7' �3 p�06�'—o�jo/6
,, . _ ,� , 1 hereby certify thaf I inspected the electrical installafion dexribed herein on the dates stated
Final
Irnestigative Fee 7�„ 2 2 c �G �0�4 � Zq�.
rTHIS INSTALLATION MAY BE ORDERED DISCONNEGTED IF NOT COMPLETED WITHIN 1 MONTHS.
OFFlCE USE ONLT This requbaf void 18 moMhs from validation date prinfed in this box.
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PLEASE PRINT OR TYPE
R�ye st Date Rou h-in ins �on r
C. s� '�� 9 pecl equiredz �es ❑ No Inspection OFher Than RougMn: ❑ Ready iVow ill Call
�(You musf call the inspeclor wher( ready) pc�fe Read�,:
I, licensed contractor ❑ owner inspection of the above elechical work at:
Job Address (Sheet, Box, or Route No.) Ci Zip Code
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Section No. Township Name or No. Range No. Fire No. Counly
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co�na�ro�
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Address (Conhactor or Owner Per�form ni g Installafion)
ed ig fur (C � a r or Owner Performing Installa
A-11 6/96 STATE BOARD COPY •
AAaster Lic. No. (Plant Elect. Only)
Phone No.
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