P - 80740�
REQUEST FOR ELECTRICAL INSPECTION °'E
��^� _ 9 8 2� Minnesota State Board of Electricity
f 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 Hh. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enier remarks in this space and on the back of the white copy only.
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Calculate Inspeciion Fee - This Inspection Request will nof be accepled without the correci fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps ,.5 0 ro 100 Am s
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY T TAL
Sign/Outline Ltg. Xfmr.
Alarm/Remote Conhol ����
Swimming Pool
I here ceAi that I ias the eleclrical inslaAafion deuri6ed hatein on the date: stated
Irrigption Boom RougMn Dare
Special Ins �
Finol
Investigative ee �C.� 0 —2-0�
THIS INSTALLAT{ON MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN t8 MONTHS.
OFFICE USE ONLY This request void 1 B months from voiidaTion date printed in This box, �
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* 0 7 9 6 9 8 2"� ,C�((}. �
PLEASE PRINT OR TYPE
Requesf Date Rough-in inspection required? ❑ No Inspection Olher Than Rough-In: ❑ Ready Now ill Call
� �Y (You must call the inspecror ready� Dafe Ready:
I, �ensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (SMeet, Box, or Roufe No.) Ciry '� Zip Code
�7 30 � ✓ht',W� �-�'1- �'nc�
Seclion No. Township Name or No. Range No. Fire No. County_ �
f� �
Occupant Phone No.
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Elechicnl Contrac�or �Company Name� Conhactor License No. Master Lic. No.
S��"S �"Icv�n�L �r4-o Zg�y
Mailing Address (Conhaclor w Owner Performing Installation)
P�-� 5 -Sf rhN sso-71
Authorized SignaNre ( onhacfor o er Performing Installa I � � Phone No. �
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E 1 b �A7E gpppD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY