P - 83352RE(1UEST FOR ELECTRICAL INSPECTION
�](� ' Q Minnesota State Board of Electricity
i�J��� �� V 1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800
Home Duplex Apt. Bldg. Other: New
ommerc' I ndustrial Farm Remoc
Air � Htg. Equip. Water Htr. Load Mgmt. Other: �
Dryer Range Elec. Heat Temp. Service
"X" above the wo�k �o, �re�y this rlq�s�Ent� arks in this space and on the back of fhe white copy
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Calculate Inspection Fee - This Inspection Requesi will not be accepted wi correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders
Mobile Home Park $tall 0 to 200 Amps to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTA}i
Sign/Outline Ltg. Xfmr. �^
Alarm/Remote Control
Swimming Pool
I hereby certify that I inspected �e elechical installation described herein on the dates stah
Irriaation Boom o..,,,.� �.. �..b
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Addn
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Fee
Investigative � t- ��~� .Zr�-Q
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
_ OFFICE USE ONLY This requast void 18 months from validafion date prinfed in this box.
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P EASE PRINT OR TYPE
Request af Rough-in inspecfion required$ ❑ Yes . No Inspection Other Than Roug In: y Now � Will Call
��' � (You must call the inspector when read �� Date Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
1ob Addreu �heef, B r Route No.) n �� _ City �� �� Zip Code
Section No. Township Name or No.
Occ �an
,
Power Supp ier
Elec ' al Contra tor (C mpany Name�
Yl �
Mailing Address (Conkac(or or Owner
Addreu
%L
Phone
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A-11 8/96 STATE BOARD COPV - SEE INSTRUCTIONS ON BACK OF YELLOW COPY
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Lic. No.