P - 82392REGIUEST FOR ELECTRICAL INSPECTION
�+.J �� 2 2 3� 8121 Uni eSs� A earRm. S-128,ISt. Paul, MN 55104
Phone (612) 642- 00�
Home Duplex Apt. Bldg. Other:> r� �� C 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 ►he white copy only.
Calculate Inspection Fee - This Inspection Request will not be accepted wiihouf the correct fee:
Other Fee # Serv' ntrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 200 ps 0 to 100 Amps
Street Ltg./Traffic Sig. Abo e 00 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL� /!S'v
Sign/Outline Ltg. Xfmr. (�(.� ��
�O
Alarm/Remote Control
Swimming Pool � — a
I hereb certi thot I ins fed the electrical installafion dex ' rei on ihe s
Irrigation RougMn Da
Special Insp i � ��
F��ai �� r
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months (rom validation date prinfed in this box.
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PLEASE PRINT OR TYPE
Request Dafe Rou ffin ins ion r uired$ Yes
��� �� g pecY eq ❑ No Inspecfion O�er Than Ro�gMn: ❑ Ready Now ❑ Will Call
(You musf call the inspeclor when ready� Date Ready:
I, ❑ licensed contractor �owner hereby request inspection of the above electrical work at:
Job Address (Streei, Box, or Roufe No.) City Zip Code
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Secfion No. Township Nam r No. Range No. Fire No. Counly
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Occupanf I Phone No.
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Power Supplier Addres � � /'� � `
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Elechical Conhactor ny Name� � Conhacror License No. Master Lic. No. (Plant Elecl. Only)
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Mailing Address �Conhactor o,�Owner Performing InsMllafion)
°7.�22 �s S�% t�//t-E2 �i9-�;D 1�I��! .S S/.�
Authorized Signature cbr or Owner Performin Install on) Phone No.
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E&00001 A-11 S/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OP YELLOW COPY