P - 81503REf�UEST FOR ELECTRICAL INSPECTION
7 5�� - 4 3 6 Minnesota State Board of Electncity
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �:
� Phone(612)642-0800
Home Du lex Apt. Bldg. Other: New Addn
ommercial Industrial Farm Remod Re air
Air C Htg. Equip. Water Hfr. Load Mgmt. Other:
Dryer Ronge Elec. Heat Temp. Service
"X" above the work covered by ihis request. Enter remarks in this space and on the back of the white copy only.
C�Z`��fYGrYYI S �G 3�1 '�/
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Calculate Inspection Fee - This Inspection Request will nof be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park $tall 0 to 200 Amps �b'Amps
Sfreet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTA �
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool '
I hereb certi that I ins ted the electrical installation deuribed herein on the dates stated
Irriqation Bo �i� �1 0......�.�_ .. .
Investigative Fee ���� _.� `��
_THIS INSTALLATION MAY BE ORDERED DISCON D IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 months from validafion dafe printed in this box.
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* 0 7 5 1 4 3 6 7* 13��
P EASE PRINT OR TYPE
Requesf te . Rough-in inspecfion required? ❑ Yes No Inspection Olher Than Rough- : dy Now ❑ Will Call
(You must call the inspeclor when read Dore Ready:
I, licensed conhactor ❑ owner hereby request inspection of the above elechical work at:
lob_ Add�re�s (Sheet, , w� No.� City� � Zip Code
I ,.�1 lJl
Section No. Township ame or No. Range No. Fire No. Coun ,n
Phone
Conhacfor (Company N - Conhactor License No. Masffir Lic. No. (Plai
�1D2 ���Yl C C `P���
ddress (Conhacbr or Owner Performing Installafion)
i � � ."�` � �N �
i Signafure � onM one No.
�`y ;
�-11 8/96 y�ATE BOARD COPY - SEE INST ONS ON BACK OF YELLOW COPY