P - 82663Y
REQUEST FOR ELECTRICAL INSPECTION
4� J- 6 2 7 Minnesota State Board of Electricity
, 1821 University Ave., Rm. S-128, St. Paul, MN 55104 �
Phone (612) 642-0800 �'���
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod e air
Air Cond. Htg. Equip. Water Htr. load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this req'Sues� �n,t�remarks i thi space and on the ba of the white copy only.
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Calculaie Inspection Fee - This Inspection Request will not be accepted wi►hout the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./TraFfic Sig. Above 200 Amps Above 100 Ai
Transformer/Generator INSPECTOR'S USE ONLY TOT,
Sign/Outline Ltg. Xfmr. � .'; /; � � ��/ ' � e
Alarm/Remote Control
Swimming Pool
Fee
I hereb certi thai I ins ted the elechical installafion described herein on ihe daies stoted
Irrigation Boom RougMn Dare
Special Inspec , �_ �
Final ' Da�
Investigative Fee � �_ L- � c l--
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OPFICE USE ONLY This requesf void 18 monfhs from validation date printed in this box.
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'K 0 4 3 5 6 G� � 5�Ic PLEASE PRINT OR TYPE
Request Date Rou h-in ins tion r uired?
9 P� eq ❑ Yes �lo Inspecfion Ofher Thon Rough-In: ❑ Ready Now ❑ Will Coll
L—/�� $� (You must call the inspector when ready) Date Ready:
I, [� licensed contractor ❑ owner herefzy request inspection of the above electrical work at:
Job Address �Sfreet, Box, or Roufe No.) � City Zip Code
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Section No. Township Name or No. Ranae No. F e N� r; ���i..
Occupanf
� e,o n nr� �
Power Supplier
Electrical Confra�r (Company
Mailing Address �Confracfor �
IS o�
Au oriz d Signature ( nhad�
1 A-11 8/96
jPhone No.
S�aba� /- 9 Z��
Address
�O e� � Conhactor License No. Master lic. No.
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tivner Perfor,m" g Ins` ( p)
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L' � 5 v / w ;a�- c y�, %'�J< <
or Owner Performing InstallationJn �v^ ^.� Phone No.
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STA OARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY
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