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P - 80318, REQUEST FOR ELECTRICAL INSPECTION — (� � p � � � /� � (� � Minnesota State Board of Electricity � L� Q `'f � 1821 Universiry Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 ��` (651) 642-0800 www.electricity.state.mn.us Home Duplex Apt. Bldg. Other: New Addn Commercial Industrial Farm Remod Repair Air Conditioner Hfg. Equip. Water Hfr. 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. ���a,e� v�,J �-�2�,a�� � nc,�� c� sv q�.� Calculate Inspection Fee - This Inspection Reque�wil�l not be accep d`it out the cor er ct�ee� ��e Other Insfallations Fee # Service Enirance Size Fee # Circuifs / Feeders Fee Mobile Home Park Stall 0 to 200 Amps 6f • 0 to 100 Amps Street Ltg. / Traffic Sig. Above 200 Amps Above 100 Amps Transformer/Generator INSPECTOR'S USE ONLY TOTAL M Sign / Outline Ltg. Xfmr. �/�.,Gi�.. � S v 3d� l" Alarm/Remote Control Swimming P I hereb certi that I ins ted the elechical installation described herein on the dates stated: Irrigation Boom Rough-In Date Special Inspection - Final - Da Investigative Fee " THIS INSTALLATION MAY BE ORDERED DIS ONNECTED IF NOT COMPLETED WITHIN 18 MONTHS. OFFICE U8E ONLY This requesf void 18 months 6om validation date printed in this box. I����III��������I�IM�������11II � �.� * 0 8 8 1 4 6 9 1* %7�5 PLEASE PRINT OR TYPE Requesf Dafe Rough-in inspection required� ❑ Yes �lo Inspecfion Ofher Than Rough-In: �eady Now ❑ Will Call 3�. � g� V� You must call fhe inspecfor when ready Oote Ready: I, icensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at: Job Address (Street, Box, or Route No.) Ciy .Zip Code � \\ o U c� s�r • `� " I Secfion No. Township Name.or No. Range No. Fire No. unty . µ, Occupani Phone No. (� ��-78��-3�Y Power Supplier � r� � � � Address �% Elechical Con}ractor / Company Name Conkacfor License No. Master Lic. No. (Planf Elecf. Only� � 0 �-3 (o Mailing A ress (Confracfor, Company or Owner Performing Installation) � �I a- A�� l� �� ��u� `q^�- Auth ized Si a (C acfor, Co y or r rmin In II i Phone Number . � (�s 1 s �-�76 EB- 1A- 5/1999 STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY