P - 80971� REQUEST FOR ELECTRICAL INSPECTION �
8 2 7� 8 4 7 Minnesota State Board of Electricity
1821 University Ave., Rm. S-i28, St. Paul, MN 55104 �;
Phone (612) 642-0800 '��
ome Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm ,�:. Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec, Heat Temp. Service
"X" above the work covered by this request. Enier remarks in this space and on the back of the white copy only.
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Calculate Ins ec on ee - his Ins ection Re uest will noi be acce ed without t e correct f: ��
Other Fee # Service Entrance ize Fee # Circuits/Feeders Fee
Mobile Home Park Stall ' 0 to 00 Amps - �C. 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Oudine Ltg. Xfmr. •c� �� `�
Alarm/Remote C
Swimming Pool
I hereb certi thaf I ins ted the elechical installation deuribed herein on the dates stated
Irrigation Boom RougMn Oate
Special Inspection
Firwl
Investigative Fee ` -
THtS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHlN 18 MONTHS.
_., OFFlCE USE ONLY 7his requesf void 18 monfhs from validation date printed in this bwc.
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PLEASE PRINT OR TYPE
Requesf Dafe Rough-in inspecfion required$ ❑ Yes o Inspecfion Other Than Rough-In: .�kady Now ❑ Will Call
\ �� (`(ou must call the inspec�or when reody) Date Reody: � .
I, �licensed controctor ❑ owner hereby request inspection of the above electrical work ot:
Job Address (Sheef, Box, or Roufe No.� Cily Zip Code
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Secfion No. Township Name or No. nge No. Fire No. ounty
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Occupant Phone No.
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Power Supplie Address
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Elechical Conhactor �Company Name) Conhactor License No. Master Lic. No. (Planf Elecl. �ly)
� Gr4-o � 3 � A
Mailing Address �Conhacfor or Owner Performing" Installation�
�t �i�- (� Sv-�° 53-// �
Aufhori d�5i9na nha or Perfor ' afi Phone No.
SS� �'/�(
E 1- 1 96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELIOW COPY
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