P - 83938,�1"8�—�349 �
Duplex
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paui, MN 55104
Phone (612) 642-0800
New
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Commercial Industrial Farm Remod
Air Cond. tg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above 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 the 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 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY T�T�L,,= r1
Sign/Outline Ltg. Xfmr. rJ"
Alarm/Remote Control
Swimming Pool
I hereb certi thaf I ins ted the elecfrical installafion described herein on the dates stated
Irriaation Boom u,.,,,.�i,, n„r�
Investigative Fee F� � �� �i �S ~��
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONiY This requesf void 18 months from validation daTe prinied in fhis box.
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I IIII II I�) II III I) III II (�I II I II III I) III I(III S� Q�
* 0 5 L 8 8 4 9 5�K PLEASE PRINT OR TYPE �S�
Reques�Dple �� (`� � Rough-in inspection required? ❑ Yes No Inspection Ofher Than RougMn: ' Ready Now ❑ Will Call
I`' 1 (You must call the inspector when ready) Date Ready: �_'� — G�
I, �licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address �Sfreef, Box, or Roufe No.) Cit�� ,. � Z� Code
Jection rvo. lownshiP Nome or No. �+ Kange I`
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Power Supplier Address
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'ee ontrador (Company Name) � /w _
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Mailing A s� a�or P i g I sfal6 fion) �-
Authorized Signature (Con r or Owner e mi Ins
B-0OOOlA-1 1 8/96 STATE BOARD COPY • SEE
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