P - 81695_ _ _ _
REC�UEST FOR ELECTRICAL INSPECTION �
��,J �- 2 4 6� Minnesota State Board of Electricit��
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �
� Phone(612)642-0800 " '
'�ome Du lex A t Bld er• New Addn
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Commercial Industrial farm � Remod
Air Cond. Htg. Equip. Water Htc Loa gmt. Other. ��� "7�_ ?QQ�
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 whiie copy only.
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Calculate Inspection Fee - This Inspection Request will rot be accepted wifhout the correct fee:
Other Fee # Service Entrance ize Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 00 Amps 0 to 100 Amps
Streei Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator e oR'S USE ONLY TOTp
Sign/Outline Ltg. Xfmr.
� � LOGvt� �- �
Alarm/Remote Control
Swimming Pool '
I hereb certi that I ins the elecfrical installation described herein on the date, stated
Irrigation Boom RougMn
Special Inspection
F��ai �2.2
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validation dote prinfed in this box.
�IIiI�IiIINII�IIiIiI��III�iI�I��i�IH��IMI � ��� •
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PLEASE PRlNT OR TYPE
� Requesf Date Rou h-in ins ecfion r uiredi �� Yes
g p eq ❑ No Inspection Other Than RougMn: ❑ Ready Now Will Call
�^ �.�' .—�^� �You must call the inspecror when ready) Date Ready:
I, ❑ licensed contractor .� owner hereby request inspection of the above electrical work at:
Job Address �Sheef, Box, or Route No.) City Zip Code
_�'� � s� �'�� ��r c � Sf. I�d� . �� i� �' � sS� 3.�
Seclion No. Township Name or No. Range No. Fire No. C nly
occupanr � ....,c.
Cs'/%/� �S G /U
Power Sup " ,
N - ' �E'nc � � ,
Eleclrical Conhacfor ICompany Name) �
Address (Conhactor or Owner Performing Insfallafion)
��x�
Phone No.
�G3 - 5 �i- �9S`�
No.
Signalure (Con or wnej/Per�orming Insfallafion� Phone No.
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11 8/ 6 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY