P - 81649• REQUEST FOR ELECTRICAL INSPECTION -
4 5 2� 8 9 6 Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
� ' Phone (612) 642-0800
Home Duplex Apt. Bldg. Other: �*—,a� New Addn
ommercial Industrial Farm J V '� � Remod Repair
Air Cond. Htg. Equip. Water Htr. �oad 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
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Calculate Inspection Fee - This Inspection Request will not be accepied without the correct iee:
Other Fee # Service Entrance Size Fee # Circuitsf Feeder,
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Sfreet Ltg./Traffic Siq. Above 200 Am s Above 100 A
Transformer/Generator INSPECTOR's uSE oN�Y TO7
Sign/Oudine Ltg. Xfmr. "
Alorm/Remote Control
S ' ' P I
copy only.
Fee
�
wimmmg o0
I herebvi certifv tlwt I insoecfed the elechital installafion described herein on the dates staled
� Investigative Fee � ""T � J� '� �-o j
THIS INSTALLATION MAY BE ORDERED pISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 monfhs from validafion dafe printed in this box.
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* O 4� 2 8 9 6�� PLEASE PRINT OR TYPE
Requesf Dato Rough-in inspecfion required? ❑ Yes
❑ No Inspection Other Than Rouglfln: ❑ Ready Now � Will Call
f"� `r,. Q f (Yo� must rnll the inspector when ready) Dofe Ready:
I, �licensed contractor ❑ owner hereby request inspection of the above elecfrical work at:
1ob Address �Streei, r Route No.) Ciy Zip Code
/ �� r o d� �r. Y'� SS
Seclion Township Name or o. Range No. Fire No. Cou y
�� �. �4-Noka�
Occupanf Phone No.
Controclor
(Conhacfor or Owner I
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nodo. w ow
/ - t,onrracror ucense rvo.
oG �<G� C6�o3z3 �
Insiallafion) � _ ./f A
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rone No.
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY