P - 82149REQUEST FOR ELECTRICAL INSPECTION �
U s� 3 7� 7(� � � Minnesota State Board of Electricity � �
� � 1821 University Avenue Suite S-12$ Saint Paul, Minnesota 55104-2993
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" (651) 642-0800 www.electricity.state.mn.us "�'
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Repair
Air Co ' er Hig. 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 the white copy only.
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Calculate Inspection Fee - This Inspection Reques� not be accepied without the correct fee:
Ofher Installations Fee # Service Enhance 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 �S
$ign / Outline Ltg. Xfmr. �� ' "'
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ected the elecfrical installation described herein on fhe dates stafed:
Irrigation Boom Ro„yh,�„ oare
Special Inspecti
Final Date �d
Investigative Fee � l—
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFflCE USE ONLY This requast void 18 monfhs from validation date printed in fhis box.
I ll� N III II Ili ll lll il III II IN I�I�III� �I I�I � aa ��
* 0 9 3 7 7 9 2 0 * ���
PLEASE PRINT OR TYPE
Request Dafe Rough-in inspection required? ❑ Yes No Inspecfion Ofher Than RougMn: ❑ Ready Now �� ill Call
���� You must call fhe inspector when ready Dafe Ready: � �
I, licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address �Streef, Box, or Route No.� Cify Zip Code
240 �.i �~� -e t-�2,Y►�• ' l SS� � Z
Section No. Township Name or No. Range No. Fire No. - County
Power Supplier ' � Address
BtHINE
/
Phone
rin�/Z
ir� fmctor mpany or�rming s RaAbllK v 7 7 Phone Number �
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�9 STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY