P - 83513REQUEST FOR ELECTRICAL INSPECTION ��°'E
i`� `t - 5 5 7 C� 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 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 white copy only.
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Calculate Inspection Fee - This Inspecti n R uest will not be accepied without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
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 INSPECTOR'S USE ONLY TOTAL .0
Sign/Outline Ltg. Xfmr. �u • S�
Alarm/Remote Control
Swimming Pool
I hereb certi ihat I ins fhe eleclrical inslallofion deuribed herein on the daYes stoted
Irrigation Boom RougMn Dare
Speciallnsp 'o
Firl-- D �
Investigative -
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This request void 18 monfhs 6om validation date prinkd in this box.
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* 0 7 2 4 5 5 7 4* �o��(J
PLEASE PRINT OR TYPE
Requesf Date Rough-in inspection required? ❑ Yes ❑ No Inspecfion OtherThan RougMn`. Ready Now ❑ Will Call
�a '�' 9� (You must call the inspeclor when ready) Date Reody:
I, licensed contractor ❑ owner hereby request inspection of the above electrica) work at:
Job Address Skeef, Bo , r Route No. Cily Zip Code
V C�2//K% • eZ
Section No. Township Name or No. Range No. Fire No. Codn
Occupant Phone No.
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Power Supp ier � Address
�Igt�cg Ri nDtr�ctor�'Company Name) Con�a�ctor}'cense No. Masffir Lic. No. (Planf Elecf. Only)
tt•�t�,� ,jBLE ELECTRIC. INC. Ci,T1Q C.�
i ing ress o . r n Inslallofion)
oon �zpids, MN 55433
Aufhorized Signature �Conhacfor ner PerForming In II on� ' F� �',a Phorre No.
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E&40001 /96 S A A COPY - SEE INSTRUCTIONS ON BACK OF YELLO