P - 830926�2---��56 �
REQUEST FOR ELECTRICAL INSPECTtON ��
Minnesota State Board of Electricity a
1821 University Ave., Rm. S-128, St. Paul, NIN 55104 �
Phone (612) 642-0800
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod
Air Con�� Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this r uest. Enter remarks in this space and on the back of the white copy only.
fuar��ce � �4 , G
Calculate Inspecfion Fee - This Inspeciion Request will noi be accepted withouf ihe correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Lig./Traffic Sig. Above 200 Am s Above 100 Ar
Transformer/Generator INSPECTOR�S USE ONLY TOT�
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
I hereb ceAi that I ins ted the elechiwl installation described herein on fhe dah
Irriqation Boom R,,,�,�,�„ n„r„
Fee
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� Investigative F� ��}� J �..��. � �!� - � V��-2�---jj
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This request wid 18 months 6om validation date printed in this box.
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PLEASE PRINT OR TYPE
Request Date Rou h-in ins ion re uired?
g pecf q ❑ Yes No Inspecfion Other Than Rough-In: Ready Now ❑ Will Call
S� ��,. (You musf call the inspecior when ready) Dafe Ready: $.. T�,,, � Q
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I, � licensed contractor ❑ owner hereby request inspection of the above electrical work at:
lob Address (Sheet, Box, or Route No.) � City Zip Code
i�as v,�Ri�.� �a�s �.r�h �Ri ��-ya�
Section No. Township Name or No. Range No. Fire No. Counly
Occupant
Pf,�,vk 1
(Company Name)
or
Phone No.
.�y- a.T3 �
:Tor License No. Master Lic. No. (Plant Elec
T W ��c�
�C� A ' � 1ek A� W
� � � . Pfione No.
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