P - 84524�F 5!' — 0 5 2 REQUEST FOR ELECTRICAL INSPECTION -_
Minnesota State Board of Electricity
1821 Uni��ersity Ave., Rm. S-128, St. Paul, MN 55104
� " Phone (612) 642-0800
Home Duplex Apt. Bldg. Other: ♦
Commercial Indusfrial Farm Ne�'" Addn
Air Cond. Htg. Equip. Water Hfr_ Load M mt. emod Re air
9 Other:
Dryer Range Elec. Heat 7emp. Service
"X" ove the work cover�td�`�fs rmuest. Enter remarks in this space and on ►he back of the white copy only.
♦
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Calculate Inspection Fee - This Inspeciion Request viill not be accepted without ihe correci fee:
Other Fee # Service Entrance Size Fee #
Mobile Home Park Stall Circuits/Feeders Fee
0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Siq. Above 200
Transformer/Generator INSPECTOR'S USE ONLY mPs Above 100 Amps �,,5�
Sign/Outline Ltg. Xfmr. TOTAL
Alarm/Remote Control � �� ���
Swimming Pool
Irrigation Boom I hereb certi that I ins ed the electrical insfallafion described herein on the dates stated e
RougMn
Speciallnspec �� �� Dare Z�
Investigative Fee F'"O�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT C MPLE WITHIN 18 MO HS.
OFFlCE USE pPl�y p�is request void 18 months from volidation dafe prinfed in this box.
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R est Date PLEASE PRINT OR TYPE
` Ra9h-i� i�specfion required? Yes ❑ No Inspection Other Than Rou Mn:
(L � l� (You must call the inspector when ready� Qa� R��. 9 ❑ Ready Now 0 Will Call
I, �licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Str Box, or Roufe No.�
(� . C�y �--� Zip Code
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Sec ion No. Township Name or No.
Range No. Fire No. County
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� Phone No. -
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Power upplier \ �
,� Address:
Elecfrical Contracfor �Company e) � `� � �`" �� C�! 7 ��U" fSl� �
^, Conhactor License No. Moster Lic. No. �Plant Elecf. Only)
I.0 �,�� ��E'�, Z� cp c� i�
Mailing Address (Contracbr or Owner Performing Installafion�
Authorized ' afure ( onfracfor � er P ing InsfallaKon) . � �� j " +�� / `
• Phone No.
EB-0pOplA-1 8/96 l —� �� -
STATE B AR� COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY