P - 78841REQUEST FOR ELECTRICAL INSPECTION -
`�Fr'-F �= 9 6 5 Minnesota State Board ot Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
Home Duplex Apt. Bldg. Other: New Addn
Commercial Indusfrial Farm Remod Re ir
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other: �O (' . ����
Dryer Range Elec. Heat Temp. Service J(,!,/L
"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 rhe 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./Tra�fic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOq'S USE ONLY TOT D, S�
Sign/Oudine ltg. Xfmr.
Alarm/Remote Confrol
Swimming P
1 her cerfi 11wt I in the elecfrical installafion described herein o� Ihe daMs staled
Irrigation B ' f Ro�Mn pa ��,1�
Special Inspection
Final pa ��7
Investigative Fee � �'7—v..�
THIS INSTALLATION MAY BE ORDERED dSCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFK;E IISE ONLY This request wid 18 monfhs from validation date printed in this box.
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PLEASE PRINT OR TYPE
Requesf Date
Rouglrin inspecfion required$ ❑ No Ins on Olher Than R Mn:
�e�� �(`�,� P� ag ❑ Ready Now ill Call
(,'� �You must call the inspecbr whe ready) pa�e Q�y.
I, '�(licensed conhactor ❑ owner hereby request inspection of the obove electrical work at:
Job Address (Shcet, Box or Roufe No.) C� P'
C� `� /�o �1v9-� v� ist � �/tr� ry��2�'J L.-t �' Z� S`Zi3
Section No. iownship Name or No. Range No. Fire No. Counly
Oc pant ���.... PhoneNo. �� ..
�,,-a IQ1 �- �'I �,r � �3-�-� � 7 � �
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Elechiml Conhactor (Co � Name) Contracrw License No, AAaster tic. No. (Plant Elect. Onl�
Qi�-' �C.r� C„ �
'ling Address�ontracpor_w Ow��,'�{or�� ro���)
L7 a �-.� •� L r- � /Y1 � � ' �7
A orized nature n r ing InstallaM1On) �� p�,,,,,Q No �
3 S�� r-J'a �—
1 A-11 8/96 `
STATE BOApD CQpY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY