P - 82730REQUEST FOR ELECTRICAL INSPECTION -
%� ��_ 8 91 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 Industria! Form 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 bc�ck 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 # Cirwits/Feeders Fee
Mobiie iiome Park Statl 0 to 200 Amps 0 to 100 Amps
Street ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'SUSE ONLY TOT
�ign/Outline Ltg. Xfmr. �d• �
Alarm/Remote Conhol
Swimming Pool
I hereb certi that I ins the elechical installafion described herein on the dales stated
Irrigafion Boom RougMn Date� �� L+Oi
Special Inspecti l ll
Final `
Investigative Fee —
THIS INSTALLATION MAY BE ORDERED DISCON IF NOT COMP_L�.TFp W HIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 months from validafion date prinied in ihis box.
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* � 4 4 8 8 9 � L�' * PLEASE PRINT OR TYPE
Requesf Dote ��� Rough-in inspecKon required$ Yes ❑ No Inspecfion O�er Than RougMn: ❑ Ready Now 0� Will Call
�� �You must call 1he inspecbr when ready) Dale Ready:
I, (�.licensed contractor ❑ owner hereby request inspecfion oF the above elecfrical work at:
Job Addreu �Sheef, Box, or Route No.) Ciy / Zip Cade
� �� /� � c Ci e � ov(Cti6vJ. I'�ri `e�� .� �.3 �
$eclion No. Township Name or No. Range No. Fire No. nty -
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Occupant y�
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Power Suppl'�er
E ' I Conhactor (Company Name)
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Moilinn Addreu IConhaclor or Owner
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�rized Signoture
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� 1 A-11 8/96
or
P{wne No.
ontractor L'icense �vo. Master
C /� 4 ( Z, �3
VIF 11�►,/ :
erforming InsfallaKof%/ �J Pho� No.
�259� � � y3�- 32
BOARD COPY - SEE INSTRUCi10NS ON BACK OF YELLOW COPY