P - 80750"' RE(�UEST FOR ELECTRICAL WSPECTION ��
Q�� ����� Minnesota State Board of Electricity
�� � � 1821 University Ave., Rm. S-128, St. Paul, MN 55104
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Phone (612) 642-0800 � p ihO `�`°'
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Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re air
Air Cond. Fitg. Equip. Water Htr. Load Mgmt. 01her:
Dryer Range Elec. Heat Temp. Service
"X" above ihe 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 Inspeciion Request will nof be accepted without the correct fee: �
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Pqrk $tall , 0 to 200 Amps � 5-� 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLV TOTA
Sign/Outline Ltg. Xfmr. • D
Alarm/Remote Conhol aO.�'O
Swimming Pool
I hereb certi thot I ins ed the elechical insfallation described herein on the dafes stated
Irrigation Boom RougMn Da�e
$peciallnspe �
Finol
Investigative ee � Q
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This requesf void 18 monfhs from validation date prinfed in this box.
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* 0 8 1 8 9 0 9 4* �a(}.�
PLEASE PRINT OR TYPE
Reques� O/ � Rough-in inspecfion required? ❑ Yes o Inspecfion Olher Than Rough-In: ❑ Ready Now Will Ca�l
9� � �You must call the inspeclor when �eady) Date Ready:
I, �.licensed confracror ❑ owner hereby request inspection of the above elecfrical work at:
Job Address �Sheef, Box, a Roule No.) Ciy . Zip Cade
�0�5 nn. ,�(�c S+. N� �R �dl� ss �
Secfion No. Township Name w o. Range No. Fire No. Coun
�
Occupant .�,� Phone No. �
Conhactor �Company Name) Conhacfor License No. �
:�d_ �e�� oN ��eC. l� 0� 17 I
Address (Contracror a Owner Performing Instal a ion)
� 1 �° . STf'a,� /�
:d Signature (Confractor r Owner Performing In Aon P'��
' �, 3 7 E.)
A-11 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY
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