P - 80142REQUEST FOR ELECTRICAL INSPECTION
8 0'� — 3 5 2� Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 551 �s
! Phone(612) 42- 80 � m ��(� "�'
/U/ /
Home Duplex Apt. Bldg. Other: /' �, New Addn
Commercial Industrial Farm r• L� Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above ihe 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 accepfed wiihout ihe correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders F
Mobile Home Park Stall 0 to 200 Amps � 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator ��:rOR'S USE ONLY TOTAL '� T
Sign/Outline Ltg. Xknr. �� U
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ted the electrical installation described herein on the dates stated
Irrigation Boom Rough-In Da
Special Inspection ' � '� ¢�'—
Fii�al � I � �`
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void y8'�months From validation date printed in this box.
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PLEASE PRINT OR TYPE
Request Dafe Rou h-in ins ion r uired? � Yes
g pecY eq ❑ No Inspection O�er Than RougMn: ❑ Ready Now ❑�II Call
�^�(7 — � Z (You must call ihe inspector when ready� Date Ready:
I, ❑ licensed confractor � owner hereby request inspection of the above elecfrical work at:
Job Addreu (Sheef, Box, or Route No.) Cily� `( Zip Code
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or
o«opanr �
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Power Supplier � /� �
X
Elechical Contracror (�emnany Name1
(Confracroror
Fire No.
A �.ok�
Phone No.
'7G'3- .5�2-�� Z 1
,�s
or Owjne Perfo� nstallafion) Phone No.
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STATE BOARD COPY - SEE INSTRU NS ON BACK OF YELLOW COPY