P - 83629REQUEST FOR ELECTRICAL INSPECTION -��..
5 0�. ' 18 3 Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
Home Duplex Apt. Bldq. Other: New Addn
Commercial Industrial Farm emod
Air Cond. Htg. 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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Calculaie Inspection Fee - This Inspection Requesf w� 1 noi e accepte wiihout the correct fee:
Other Fee # Service Entrance �ze Fee # Circuits/Feedc
Mobile Home Park Stall � 0 to ' Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100
Transformer/Generator INSPECTOR'S USE ONLY TS
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
Irriaation Boom
Fee
�t�a
fhaf I ins fed ihe electrical insfallafion described herein on the dafes stafed
oare
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFflCE USE ONLY This requesf void 18 monfhs from validafion date prinfed in ihis box.
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Request Dale Rougfrin inspection required? ❑ Yes o Inspecfion Olher Than RougMn: ❑ Ready Now ill Call
�`�� �� �You must call ihe inspecfor when ready� Dare Ready:
I, licensed contractor ❑ owner hereby request inspection of the a�ove electrical work at:
Job Address (Sheet, Box, or Route No.) . City � Zip Code
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Seciion No. Township Name or No. Range No. ire No. unty
Occupant
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Power Supplier
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Elechical Conhactor (Company Name�
L./���'�5": ��� .���
Moiling Addreu (Conhacfor or Owner Performing
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Authorized 'gnature (Conhacfor Owner�$erfon
8-000� 8/96 ��
STATE BOA
Phone No.
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jress
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Conhacfor License No. Masler Lic. No. k
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530
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