P - 84013REQUEST FOR ELECTRICAL INSPECTION °'E
4�°� ��� O � Minnesota State Board of Electricity
��d. 0 1821 University Ave., Rm. S-128, St. Paul, MN 55104
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Phone (612) 642-080(Y "�'
ome Duplex Apt. Bldg. Other: � New Addn
Commercial Industrial Farm Remod Re air I
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer ange Elec. Heat Temp. Service ;
"X" above the work covered by tnis request. Enter remarks in this space and on the back of the white copy only. I
Calculate Inspection Fee - This Inspection Request will nof be accepted 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 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Outline Ltg. Xfmr. ��•
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ted }he electrical installation described herein on ihe dates stated
Irriaation Boorr� h. 1•~� e,.,,,.ti_i., n��,.
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Investigative Fee � � �� � � � '��_
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validation date printed in this box.
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* � 4 9 L 1 3 8 4�k PLEASE PRINT OR TYPE OJ '���
Request Date Rough-in inspection required? ❑ Yes No Inspection Other Than Rough-In: Ready Now ❑ Will CaII
ti���, ��� (You must call fhe inspector when ready) Date Ready:
I, �licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Str Box, or Ro e No.) Cify Zip Code
1 g� t�-�i c,2 �(a_.e�--��ra,c.� � 5543
Section No. Townshio Name or No. Ranqe No. Fire No. Co
Occupant
Power
�—
Phone No.
5� t — Fs�£S' 1
Confractor �Company Name� Conkactor License No. Master Lic. No.
� I�n� 5 1����� L � d2� � 3�
�ddr s � onhactor o Owner PerformI'^� Installation�
� l�i t-�-e._ �- � �9�. • � -
or Owner Performing Installation) ���j`�pY[� � V I Ph� No. ^� _ `
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BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY