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P - 83199REf�UEST FOR ELECTRICAL INSPECTION � 5 � 2- 4 9 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: CC�je. New Addn Commercial Industrial farm C7 5 Remod Re air Air Cond. Htg. Equip. Water Htr. load Mgmt. Other: Dryer Range Elec. Heat Temp. Service "X" above the work covered by this requesi. Enter emarks in this space and\on the back of the white copy only. U,r�oe,r9souhc� '���� �O .��Of� Shec� ISF�r�p Ct�CCV.��} J s'p'�s� Calculate Inspection Fee - This Inspecfion Request will not be accepted without fhe correcF fee: Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps Transformer/Generator INSPECTOR'S USE ONIY TOT�� � � Sign/OuNine Ltg. Xtmr. Alarm/Remote Confrol Swimmina Pool tfwt I insoecled the herein on the da _� .S � � Invesfigative Fee � � C_���r � — � I�O'—/ -�� J" THIS INSTALLATION MAY BE ORDERED dSCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS. OFFlCE USE ONLY This request void 18 months from validafion da�e printed in this box. ���� �� ���� �--�-��.y� ��'.�� I III IIIIIII IIIIIIIIIIII��II�I ��,/�C�'� * 0 5 3 2 4 9 7 5�C �'�'�./ /'pLEASE PRINT OR TYPE Request Date Rou h-in ins on r uired$ ❑ Yes 9 pecfi eq ❑ No Inspeclion Olher Tfwn Raigh-In: ❑ Ready Now 0�11 CaU �-1g -q g (You must call the inspector when ready) Date Ready: I, ❑ licensed contractor � owner hereby request inspection of ihe above electrical work at: lob Addreu (Street, Box, or Route NoJ Ciy Zip Code S � � r:,� � Ss'{ 3z Seclion No. Township Name or No. � Ra�e No. Fire No. � Counfy Occupant Mailing Address (Conkador or Owner or Pho�e No. S Conhacror license No. - �13g 3 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY 3� I - y3s3