P - 80745> REQUEST FOR ELECTRICAL INSPECTION °":
O�j ����� � Minnesota State Board of Electricity
«L 1821 University Ave., Rm. S-128, St. Paul, MN 55104
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Phone (612) 642-0800 `�'
Home Duplex Apt. Bidg. Other: New Addn
Co I Industrial farm Remod Re air
Air Htg. Equip. Woter Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
'X" above the work covered by ihis requesl. Fnier remarks in ihis space and on the back of the white copy only.
Cokulate Inspection Fee - This Inspeclion Request wi!! not be .accepted wilhout the correci fee:
Other Fee # Service Entranc Size Fee # Circuits/Feedi
Mobile Home Park Stall 0 to 200 Amps 0 to ) 00 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100
Transformer/Generator INSPECTOR'S USE ONLY TC
Sign/Outline Ltg. Xfmr. o
Alarm/Remote Conhol
Swimmin Pool
Fee
9 I hereb certi fhai I ins ected the elecirical insfallafion described herein on if�e daTes sfated
Irrigation Boom Rough-In Dafe
Special Inspecfi
Fi�f01' Dar�.
Investigative Fee /d �' � � ' Q3
THlS INSTALLATION MAY BE ORDERED DIS NNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
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OFFICE USE ONLY This request void 18 months from validation date prinfed in fhis box.
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PLEASE PRINT OR TYPE
Request Date R h-in ins �on r uired?
p. oug pecY eq ❑ Yes No Inspecfion Other Than Rough-In: � Ready Now ��II Calf
g��Q ��' 9 (You must call the inspector when ready) pote Ready:
I, � licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Addreu �Sheef, Box, or Route No.) Ciy Zip Code
/60- PQno r�ina A-�� �E F-�� le
Section No. Township Name or No. RanAe No. Fire No. ounN
/�h0 �
I Phone No.
A .�atr'��n �� n rY, ew S7� -
er Address
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Eleckical Conhacfor (Company Name)
/2'TS �GEC'( � � �
Mailing Address �Confracfor or Owner
g7�0 o�S7� /
Authorized Siqnafure fConhacror or O�
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� Confractor License No. Master Lia No.
G'�o i y8�
nllafion)
w . 3s398'
3 Insfallafion� Phone No.
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COPY - SEE IMSTRUCTIONS ON BACK OF YELLOW COPY