P - 84611Itlll I��) IIII� II II) I) II) I) I!) (IIII IIIII IIIII IIIII g21�Uni e s�OAve. dRm. SRi SASt.IPauP MN 550104 ���,,�
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Home Duplex Apt. Bldg. OMther: ' y�? ��-i New Addn
Commercial Industrial Farm t'�P1 `l rr �� Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
D er Ran e Elec. Heat Tem . Service
"X" above the work covered by this request. Enter remarks in ihis space and on the back of ihe white copy only.
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Colculate Inspection Fee - This Inspection Request will not be accepfed without the corred fee:
Olher Fee � Service EMrance Size Fee # Circvits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps �. GC '� 0 to 100 Amps /t�. C'C
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOH'SUSEONLY TOTAL
$ign/Outline Ltg. Xfmr. •�� �7
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ecied the elecfrical installation described herein on fhe dates sMfed
Irrigdtion Boom Rough-In Dote
Special Insp
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Investigative -
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
2 9 9� n� n/ � OFFICE USE ONLY This request void 18 months from validation dak printed in this box.
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PLEASE PRINT OR TYPE
Requ st Date Rough-in inspecfion required2 ❑ Yes �No Inspeciion Ofher Than Rough-In: � Ready Now �VJill Cal�
�/ O.r� � (You must call the inspedor when ready) Date Ready:
I, � licensed contracFor ❑ owner hereby request inspection of ihe above electrical work at:
Job Address (Street, Boa, or Route No.) Ciry Zip Code
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$ecfion No. T�p'Merne+rllw �. Range No. Fire No. Counly
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pu a�� Phone Np.
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Powe� S ppli r Address
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Elechical Contrador (Compony Name) :Z .i] onhaclor License No. Mashr Lic. No. (Plant Elect. Only)
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Mailing Address (Conhactor oi Owner
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1A-10 6/ STATE BOARD COPY- SEE
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COPY
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