P - 82413RE(�UEST FOR ELECTRICAL INSPECTION �
'� �� /� �� 7�] � Minnesota State Board of Electricity
�"t � � 1821 University Ave., Rm. S-128, St. Paul, MN 55104
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Phone (612) 642-0800 '�°
Home Duplex Apt. Bldg. Other. New Addn
Commercial Industrial Farm Remod Re ir
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other: , � �J i
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by ihis request. Enter remarks in this space and on ►he back o he white copy on�y.
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Calculate Inspection Fee - This Inspection Reqvest 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/Generator INSPECTOR's uSE ONtY TOTAL
Sign/Outline Ltg. Xfmr. C�
Alarm/Remote Control
Swimming Pool
1 hereb certi Ihat I ins the elechical installation described herein on the dales stated
hrigation Boom RougMn
Special Inspection - 1i �`��
Find
investigative � � ' C'.�%
THIS INSTALLATION MA BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 AiiONTHS.
OFFICE USE ONLY This request void 18 monfhs from validafion dafe prinfed in ihis box.
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* O 4 7 4 S 7 7 4'�' PLEASE PRINT OR TYPE
Requesf Dafe /� R h-in ens fion r uired2 �yes
�-'� O� oug pec eq ❑ No Inspection Ofher Than Rough-In: ❑ Ready Now ill Call
(You must call the inspec�or when ready� Date Ready:
I, � licensed contractor �owner hereby request inspection of the above electrical work at:
Job Addreu �Sheet, Box, or Route No.) Cily Zip Code
?3S! / S
Seclion No. Township Name or No. Range No. Fire No. ouny
OccupaN � Phone No.
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Power Supplier Addreu
5 �. �i'� %3S! ��%
Elechical Conhactor (Company Name) Conhador License No. Master Lic. No. �Plant Elect. Only)
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Mailing Add�ess (Conhactor or Owner Perfo�m'i�InstallaHon) . �
O /7dS eT '1..� L1
Au ri Signature �Conhacfor or Owner Performing Installalion) Phone No.
9s� S'��'-/9?d
E A- 1 8/96 STATE BOARD COPY - SEE INSTRUCTONS ON BACK OF YELLOW COPY