P - 81013REQUEST FOR ELECTRICAL INSPECTION �
8�JL_ � 15 6� Minnesota State Board of Electricity
� 1821 University Ave., Rm. S-128, St. Paul MN 55104 �
Phone (612) 642-0800 r��p �/n `'�'
Home Duplex Apt. Bldg. Other. ���l� � SZ) New Addn
Commercial Industrial Farm �� Remod Re air
Air Cond. Hfg. Equip. Water Htr. Load M mt. 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 copy only.
Colculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Ent ce Size Fee # Circuifs/Feeders Fee
Mobile Home Park Stall 0 to 200 p 0 to 100 Amps -Ob
Sheet Ltg./Traffic Sig. Above 20 Am s Above 00 Amps
. Transfo�mer[Generotor � iNSPecroR•s use oN�v TOTAL '}�
Sign/Ou#(ine Lt . Xfmr.. �/�- �{�/c. ��SV
Alarm/Remote Control
Swimming Pool
I hereb certi thoi I ins ted the elechical installation described herein on the dates stated
Irrigation Boom Ro�9�l� ��,��to Da �'� \
Special Insp
Final at
Investigative ee ' � - '
THIS INSTALLATION MAY BE ORDERED DISCO ED IF NOT COMPLETED ITHIN 18 MONTHS.
OFFlCE USE ONLY This requeat void 18 months from validation date prinied in fhis box.
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PLEASE PRINT OR TYPE
� Reqoest Date Rough-in inspection requi�ed? ❑ Yes No Inspection Other Than RougMn: ❑ Ready Now ill Coll
� ' �. l. —�� (You musi call the inspecfor when ready) Date Ready:
I, ❑ I+censed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address �Streef, Box, r Rarte No.) City Zip Code
1`�"� � -� � �� ��► , � Z
Seclion No. Township Name r No. � Range No. Fire No. County
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panf Phone No.
� d ' Ih � dt. � r— 5
Power Suppl � Ad ress
P 5. �� �,s �
Electrical Conhactor �Company Nom� .� onhador License No.>,_ .: Master Lic. No. �Plant Elect. Only)
. - • l.�C.� �
�� Mai ing Address (Conkactor or Ownepi�'eP�orming Insfallation) ..
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A fho ' edSignatur'�Conhaclor r Owner P�rForming Ins o � e Phone No.
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E&00001 A-11 S/96 STATE BOARD C PY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY