P - 83027REQUEST FOR ELEC7RICAL INSPECTION ���
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6��� 1� 4 Minnesota State Board of Electriciry '�
�• � 1821 Universiry Ave., Rm. S-128, St. Paul, MN 55104
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' 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 no► be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Sroll 0 to 200 Amps a 0 to 100 Amps �QaG
Sireet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR�S USE ONLY TO L
Sign/Oudine Ltg. Xfmr. � s. S�
Alarm/Remote Confrol
Swimming Pool
I hereb certi that I ins the eleckical insMllafion described herein on the dales sta�ed
Irrigation B - RougMn � G Da ,�7 �, �/
Special lns S
Final Date
Investigative Fee .— �' .-P90
THIS INSTALLAjION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS,
OFFlCE USE ONLY This requesf void 18 months from validation date printed in fhis box.
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PLEASE PRINT OR TYPE
Requesf Date Rough-in inspection required$ ❑ Yes ❑ No Inspection Olher Than Rough-In: ❑ Ready Now 0 W�II Call
(You must call the inspecfor when ready� Date Ready:
I, icensed contractor ❑ owner hereby request inspection of the above elecfrical work at:
Job P.ddress (Sheef, $ox, or Route No.� Cily Zip Code
3 � ��e �a�. ssy3
Secfion No. Township Name a No. Range No. Fire No. nty
Occu nf Phone No.
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Power Su�plier Address
:tor �Company Name) Conhactor License No. Masfer Lic. No. �Plant Elect.
� �ah�C..�VW �nt-t7 G� Ou�j�
�Conhador or Owner Perfo ing Installofion)
�5ia � 'J S�{2'�j
iNre �Conhacror or er Performing Install n; i Phone No.
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96 �7p7E BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY