P - 81467REQUEST FOR ELECTRICAL INSPECTION -
� LJ '�t - 6 2 4 Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
Home Duplex Apt. Bldg. Other: New ddn
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 ihe white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted without ►he correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Sheet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Oudine Ltg. Xfmr. ,�'�
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ted the electrical instollafion described herein on the dates stated
Irrigation B -� . Rough-In pa�
Speciallns ` �
Final p �
Investigative Fee ��
TF:IS INSTALLATION MAY BE ORDERED DI ECTED IF NOT COMPLETED WITHIN 18 MONT .
OFFlCE USE ONLY This request wid 18 monfhs from validafion date prinfed in this box.
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* 0 6 0 4 6 2 4 7�z 75'
PLEASE PRINT OR TYPE
Requesf Dafe Rough-in inspecfion required$ ❑ Yes No Inspecfion Ofher Than Rough-In: Ready Now ❑ Will Call
�� l t��� (You must call fhe inspecfor when ready) Dafe Reody:
I, �licensed conhactor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sheef, Box, or Route No.) City Zip Code
I5 1 c�. (��('�e.(L �ri �3 �
Section No. Township Name or No. Range No. Fire No. o
�� �
Occupanf
�' �� �� Phone No.
Power Supplier Address �� � � ��
Elechical Conhactor �Company Nam , Conhacfor License No. Masfer Lic. No. (Plant Elecf. Only)
ris �.�e G `C..�ooit 3
Maili� dress Conkactor or Owner Performing Installafion) —
–\
Au iz ture �Conhactor or Owner Performing Insfallafion� J_� � � Phooe No.
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E 1 -11 8/96 �` ��
STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COpY