P - 82130REQUEST FOR ELECTRICAL INSPECTION
7 Q�� Q(a � � Minnesota State Board of Electricity
�l V J 1821 University Ave., Rm. S-128, St. Paul, MN 55104
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` Phone(612)642-0800 "�'
ome Duplex Apt. Bidg. Other: New Addn
Commercial Industrial Farm Remod Re air
Air Cond. Htg. Equi . Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in Ihis space and on the back of the whiie copy only.
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Calculaie Inspection Fee - This Inspection Request will not be accepfed without the correct fee����
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig, Above 200 Am s Above 100 Amps
TransformerjGenerafor INSPECTOR'S USE ONLY TOTAL
Sign/Outline Ltg. Xfmr. °
Alarm/Remote Control � Q � �
Swimming Pool
I hereby certify that I inspecled Ihe eleclrical inslaNation described herein on lhe dates sMPed
Investigative Fee � �� '� �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPIETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 months (rom wlidafion date printed in this box.
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PLEASE PRINT OR TYPE
Requesf Date '� Rou h-in ins on r uired? ❑ Yes pec g ❑ Ready Now 0�11 Call
g pecli eq ❑ No Ins fion Other Than Rou Mn:
�� (You must call ihe inspecfor when ready) Date Ready:
I, �censed contractor ❑ owner hereby request inspection of the above electrical work at:
1ob Address (Sfreef, Box, or Roule No.� Ciy Zip Code .
1 � � / 42�:�. � �.� I�ea.�� �i�i�� �5�5��.�.
Secfion No. Township Name�o. Range No. Fire No. Counh/ V
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Occupant � Phone No��r �O � �
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Power $upplier Add2 � -
1� C.s 1��� ,��u�s���
Elechical Contmctor (Company Name) Conhacfor Gcense No. Masfer Gc. No. (Plant Elecf. Only)
� .� � � C, ac� 73 �
Mailing Ad ss �Co�hacror w Owner Performing Installafion� �
19' F - " %�. ���aJ
Aufhorized Signature (Conkacf�,{ or Owner Performing Installafion) �•t Phone No.
1 V/ /Y i/ Ui 1 7� 7 78�I-��'oc
STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY