P - 82655RE(]UEST FOR ELECTRICAL INSPECTION
O� n O('� Minnesota State Board of Electriciry
J J 1821 University Ave., Rm. S-128, St. Paul, MN 55104 �
Phone(612)642-0800
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm emod Re air
! Air Cond. Htg. Equi . Water Htr. Load Mgmt. Other:
� Elec. Heat Temp. Service
"X above the work covere y this request. Enter remarks in this space and on the back of fhe white copy only.
Calculafe Inspection Fee - This Inspeciion Request will not be accepfed without the correct fee:
Other Fee # Servi e Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 00 Amps ' � 0 to 100 Amps
Street Ltg./Traffic Sig. Ab e 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TC�TAL
Sign/Outline Ltg. Xfmr. 4S
Alarm/Remote Control
Swimming Pool � J�
I hereb certi that I ins ected the electrical installation described herein on thd�ates a e �
Irrigation Boom Roughan �a�
Speciallnspectio r- �' 2
Final
Investigative Fee • — —
ru�c in�crei i eT1(]N MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 1 MONTHS.
OFFICE USE ONLY This requesf void 1 8 months From validation date prinied in this box.
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* � 4 �❑ 9 � 9 8* PLEASE PRINT OR TYPE
Request Date Rough-in inspecfion required? Yes
❑ No Inspection Other Than Rough-In: ❑ Ready Now ❑ ill Call
L� �You must call the inspecfor when readyJ Date Ready:
I, icensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sheet, Box, or Route No.� Ciy Zip Code
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�-A T��.i. �� 4�n� l b Le
Secfion No. Township Name or No. Range No. fire No. Counry
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���P` � � Phone No.
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2.SyL�
Power Supplier � Address
Electrical Conhactor (Company Name) Conhacfor License No. Master Lic. No. �Planf Elect. Only)
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Mailing Address er ni tio� �
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Aufhorized Signatu or or er Pe ormi Insfallafio Phone No.
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EB-0OOOlA-11 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY