P - 83911491-127 �
Nome
REQUEST FQR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
Other: New
Commercial Industrial Farm (�,�2._
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
Remod
copy
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance ' Fee # Circuits/Feeders
Mobile Home Park Stall 0 to 00 Amps . 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amp:
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Outline Ltg. Xfmr. �
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ted the electrical installation described herein on ihe dates st�
Irrigation Boom Rouah-In Date
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Addn
Fee
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THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 1 S monihs from validation dafe printed in this box.
I(�II I� �II II �II I) III II III III II II) II III I IIII
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* O 4 9 L L 2 7 7�K PLEASE PRINT OR TYPE � 5�
Request Date Rough-in inspection required? ❑ Yes � No Inspecfion Other Than Rough-In: Ready Now 0 Will Call
' Ip _�, -M (You must call the inspector when reaay) Date Ready:
I, ,�licensed contractor ❑ owner hereby request inspection of the above electrical work at:
106 Address �Street, Box, or Roufe No.) City Zip Code
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Section No. Township Name or No. Range No. fire No. Cou ,
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ier Add
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nhacfor �Company Name) �
I�i f i S �j ��1.R1�4� Y 1 �
�ess (Conhacfor or Owner Performi Installation)
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i ture (Co cc(or or Owner Pe or ing Installatior
� �9 STATE BOARD COPY - SI
Phone No.
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ntractor license No� Masfer Lic. No. �Piant Elecf. Only)
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Phone No.
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