P - 84674REQUEST FOR ELECTRICAL INSPECTION --
'� V L=19 5 Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800 �
ome Dupiex Apt. Bldg. Ofher: New ddn
Commercial Indushial Farm Remod Re ir
Air Cond. . 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.
Calculafe Inspection Fee - This Inspection 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
Sheet ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL �� ��
Sign/Oudine Ltg. Xfmr.
Alarm/Remote Conhol
Swimming Pool
I hereb certi that 1 ins ted the elechical installation described herein on the dates stated
Irrigation Boom RougMn Dare
$peciallnspecti �
, , _- Final � � �°te � <
Investigative Fee _ _ --�� C� �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 monfhs from validafion date printed in this box.
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* 0 4 6 2 1 9 5 9* PLEASE PRINT OR TYPE
Requesf Date f /,�� � Rough-in inspection required? ❑ Yes o Inspeclion Olher Than RougMn: eady Now ❑ Will Call
t� �% (You must call the inspector when ready) Date Ready:
�,�licensed contractor ❑ owner hereby request inspection of the above elecfrical work at:
Job Address (Sheef, Box, or R o.� City % Zip Code ,`� �
) �'' _ Gtn 1��-2 %� ' �- {^ r 1��, j ., � z
Seclion No. Township Name or No. Range No. Fire No. County / ��
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Occupanf /� � Phone No
u ,� r �` 7�-� �- dL e�
Power $upplier Address
Elecki tonhac�or �Com ny N Conhaclor License No. Master Lic. No. (Plant Elecf. Only�
a r �C� c�tr'u.� ��� e o
Mailing dreu Confra4fw w Owner ,Pe�°�^ing Insfall fion)
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AulFiorized Si nalure ConhacMr w Owner Performi InsfallaY n Phone No.
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E&OOO��p"� � a STATE 90 PY - SEE INSTRUCTONS ON BACK OF YELLOW COPY