P - 82261RE(�UEST FOR ELECTRICAL INSPECTION °'E
8 Q,� � 211 � Minnesota State Board of Electricity ;
y 1821 University Ave., Rm. S-128, St. Paul, MN 55104 �
Phone (612) 642-0800 „
Home Duplex Apt. Bldg. Othe : �Q�'� New
Commercial Industrial Farm .� s� Remod
Air Cond. Htg. Equip. Water Htr. Load gmt. 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.
Calculate Inspection Fee - This Inspection Request will not be accepted withoui ihe correct iee:
Other Fee # Serv' ntran iz Fee # Circuits/Feeders
Mobile Home Park Stall 0 20' mp O, a'O 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Ar
Transformer/Generator INSPECTOR'S USE ONLY TOT�
Sign/Oudine Ltg. Xfmr.
Alarm/Remote Confrol
Swimming Pool
Irripation Boom
Fee
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I hereb certi that I ins ted the elechical installation described herein on the dafes stated
RougMn ^ �� — � �a 2� Daj��
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THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 monfhs from validation dafe printed in this box.
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PLEASE PRINT OR TYPE ��
Requesf Dafe Rou h-in ins ion r uired?
g pecl' eq ❑ No Inspacfion O�er Than Rough-In: ❑ Ready No 'll Call
�• %��:%� (You must call fhe inspector when ready) Date Ready:
I, �ensed contractor ❑ owner hereby request inspection of the above eleckical work at:
Job Address (Sheet, Box, or Roufe No.� City Zip Code
"70� D�A�u� �/� , � �`���
Secfion No. Township Name or o. Range No. Fire No. Cou
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���Pa^� Phone No.
ox w e l� C'io -� 57�/' .
Power Supplier � �� A Addre �� ' � � �� �/ �
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Elechical Conhacror Company Name) � Conhactor License No. Master Lic. No. (Plant Elect. Only)
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Mailing Address (Co cior or Owner Performing Insfallafion) ' ��
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Aolhotized Sipnature ICon7aciri or Owner Per%rmina Installafionl Phnnw Nn
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BOARD COPY - SEE INSTRUCTIONS-ON BACK OF YELLOW COPY