P - 81493RE�UEST FOR ELECTRICAL INSPECTION -
5� L� 5 5 8 � Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
' Phone (612) 642-0800
Home Duplex Apt. Bldg. Other: New Addn
Commerciai Industrial Farm emod " Re ir
Air Cond. Htg. Equip. Wafer Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above fhe work covered by this request. Enter remarks in this space and on the back of the white copy only.
Calculate InspecFion Fee - This Inspection Request will not be accepted withoui fhe correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps , Q •
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTALy !�
Sign/Oudine Ltg. Xfmr. pJQ. J
Alarm/Remote Conhol
Swimming Pool �_/J i `�� s�
I hereb certi ffwt I in Ifie eleclricol instalbtion describedASe�n" n tiie stal�} T
Irrigation Boom' RougMn
Speciallns �/� _ �
Final
Investigative Fee ��-ibp �O� �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 8 MONTHS.
OFFICE USE ONLY This requesf void 18 months kom validation date printed in this box.
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PLEASE PRINT OR TYPE
Request _�'� Raugh-in inspection required$ �Yes ❑ No Inspeclion 011�er Than RougMn: ❑ Ready Now Will Call
l(You must call fhe inspacior when �eody) Dafe Ready:
I, ❑ licensed conhactor � owner hereby request inspection of the above electrical work at:
1ob Address (Sheef, Box, or Roule No.) Ci1y Zip Code
1�68 NaQ..r� �,,�sa�2u.c1(, Dn,v� F,e,�o�Ey Mn1 -�s�/3�.
Secfion No. Township Name o�o. Range No. Fire No. County
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Occupanf phone No
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Power Supplier Addreu .I
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Elecirical Conhaclor ny Name) Contracror License No. Master Lic. No. (Plant Elect. OnIyI
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Mailing Addreu (Conhactor or Owner Pehorming Installotion�
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' naNre (Conhacfor or Owner mg In lation) - � Phone No.
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