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P - 82948REQUEST FOR ELECTRICAL INSPECTION �� � � � -7 � � � 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 Commercial Industrial Farm Remod Re air Air Co Htg. Equip. Water Htr. Load Mgmt. Other: Dryer Range Elec. Heat Temp. Service "X" abo e work covered by this request. Enter remarks in this space and on the back of the white copy only. e�i bh �.�, �cK� �+�-�- a,o. c� w► r� � d d►-�� �,..t � a hoks.e� Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee: Other Fee # Service Entranc ize Fee # Circuits/Feeders Fee Mobile Home Park Stall t 0 mps 0 to 100 Amps Sfreet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps Transformer/Generator INSPECTOR•s use oN�r TOTAL C Sign/Oudine Ltg. Xfmr. � • 7 � Alarm/Remote Control Swimming Pool I hereb certi that I ins ted the eleclrical installation described herein on the dates sMted Irrigation BOOrti� � Rough-In � � D Special Insp � _ 'Z � Final Da� 7 � Investigative Fee �-v THIS INSTALLATION MAY BE ORDERED DISCONNEGTED IF NOT COMPLETED WITHIN 18 MONTHS. . OFFICE USE ONLY This requesf void 18 monihs from validation dafe printed in this box. � I� �� III II I�� II �II��� I�� �i II{ �� {I� II �� �(� •. 7� � * 0 6 3? 7 6 3 4* ��`'�O� PLEASE PRINT OR TYPE Request Dafe Rou h-in ins on r uired$ es g pecfi eq ❑ No Inspection Other Than Rough-In: ❑ Ready Now ❑ Will Call . ��� �� 4 (You must call the inspector when ready) Date Ready: 1,�licensed controctor ❑ owner hereby request inspection of the above electrica) work at: Job Addrass (Sheet, Box, or Roufe No.) Ciy Zip Code oa o� o,,.� O�e�� N r- F�,� dl� 55ti3 a Section No. Township Name or No. � Range No. Fire No. County / �%d�iil� Occupont Phone No. S-�ee�- i�e� e.,�.� 5��- qy2(o Power Supplier Address N S � 3!!5 ('e.wi'.t otcv� �% Elechic I Co hactor �Company Name) � Conhacfor License No. Master Lic. No. �Plant Elecf. Only) . i�e�e.l. �/c�-��� ��' � �, ao d 5 D b Mailing Address �Conhactor or Owner Perfo�ming Insfallafion) J q 2 0 0 �'Sa n�� S-�i � YV � lI4 ai1C-� %1%h% ,�S �i Y% Aufhorized Sig fure �Conhactor or Owner PefForming In IaKon) Phone No. 7B'3 - 2S1 d' EB-0OOOI A-1 1 8/96 STATE BOAHD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY