P - 84290�
�1�,-476 m�
Commercial Industria
Air Cond. Htg. Eqi
Dryer Range
"X" above the work covered I
REf�UEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800
Other: New
Farm Remod
Wcter Htr.
Elec. Heat
request. Enter
Mgmt. Other:
Service
in this space and on the back of the white copy
Calculate Inspection Fee - This Inspection Request will nof be accepted withouf the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders
Mobile Home Park Stall to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Ai
Transformer/Generator INSPECTOR'S USE ONLY TOT,
Sign/Outline Ltg. Xfmr. '
Alarm/Remote Confrol
;�..._....
� a,u�,n
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Fee
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Swimming Pool
I hereb certi that I ins ted the elechical installation dexribed herein on the dafes stated
Irrigation Boom f. ' - RougMn '
Special Inspecti � '� ' �._ � p � � Z/� `7
��e � . C � Final � — – fi} .� f
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THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validation date prinied in this box. �
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* � 4 1 1 4� 6 5* PLEASE PRINT OR TYPE
Request Dafe Rou h-in ins fion r vired? Yes pec g ❑ Ready Now 0 Will Call
9 P� eq ❑ No �ns tion Ofher Than Rou h-In:
1^ ZQ s—� (You must call the inspector when ready) Date Ready:
I, �censed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address �Sfreet, Box, or Roufe No.) City Zip Code
yo s� l �. �, c� --� �
Section No. Township Na e or No. Range No. Fire No. ounN
Occupanf
�-�w V�S (
Power Suoolier
f�
(Company Name)
�l ,'c
nhaclor or Owner Pedorming
. n i
Phone No.
S7� �c
Conhacfor License No. Master
C 22
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1 S/96 ( �
STATE BOARD COPY - S E E I N S T R U C T I O N S O N B A C K O F Y E L L O W C O P Y