P - 83864REQUEST FOR ELECTRICAL INSPECTION
G ���� ��'] � Minnesota State Board of Electricity
5-�-1- i 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 Inspection Request will not be accepted 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 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL ��—
Sign/Outline Ltg. Xfmr.
Aiarm/Remote Control
Swimming Pool I hereb certi that I ins ed the elecfrical installafion described herein on fhe dates sMted
Irrigation Boom Rough-In �fe
Speciallnspecti � pa
_ N Final �G�.. � ,�
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 1 8 month, from validation date printed in tfiis box.
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* O S L°I O 7 7 2�K PLEASE PRINT OR TYPE �'S' �
Requ st,Pate Rough-in inspection required? ❑ Yes No Inspection Other Than RougMn: ❑ Ready No Will Call
U(You musf call the inspecior when ready) Date Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sheet, Box, or Route No.) ��` Ci ,� / Zip Code /
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Section No. Township Name or No. Range No. Fire No. County.n _,� �
�n
Power Suoolier
Phone
Electrical Cory� c r :�pyj�a� Confracfor License rJ,p. Master Lic. No. (Plant Elect. Only�
n i�. ELECi.� INC. �l
Mailing Address onk n�r�f�re�iw�l�stallation)
1�11�� .'iJ�7�l�4
Authorized ture (Co actor ner PerForm�,q Installafion) M C, �/ P�Qy��fe-�� `� �-�
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EB-00001 A-1 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY