P - 83626� f f REGIUEST FOR ELECTRICAL INSPECTION �`:�..
I�) II �I II III II I�I I) III II III I IO I�I �I I�I I I� Minnesota State Board of Electricity e`�. ���
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`* a 2'� 4 3 9 8 8 * Phone (612) 642-080 Rm. S 12a, st. �z�i, MN 55104 �_ �
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Home Duplex Apt. Bldg. Other: �� New Addn
Commercial industrial Farm Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Tem . Service
"X" ab e the work covered by this requesf. Enter remarks in this space ond on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Olher Fee # Service Enhance Size Fee # Circuih/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps , Q
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR•SUS N�v TOTAL,ti
$ign/Outline Ltg. Xfmr. � �: � �l �
Alarm/Remote Control ` �% �--
Swimming Pool
I hereb certi that I ins eded the eledrical installation described herein on }he dates stated
Irrigation Boom ` Rough-In i ��� �
Special lnspe ' '�—. �C-'-�
Final p
Irnestigative F ,
THIS INSTALLATION MAY B� ORDERED DISCONNECTED IF NOT COMPLETED WIT N 18 ONTHS.
2 9 9- 3 9 8� OFFICE USE ONLY This request void 18 monihs from validation date printed in }his box.
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PLEASE PRINT OR TYPE � � �
Requesf ate Rough-in inspedion required2 ❑ Yes � No Inspection Other Than Rough-In: � Ready Naw � Will Call
��— – 9� (You must call }he inspedor when ready) DaTe Ready:
I, ❑ licensed contractor � owner hereby request inspection of the above electrical work at:
Job Address (Sireet, Boz, or Route No.) City / y � Zip Code
76d� T wt-�o /�!^r�C`e -�r �� �C ( p�l /"l N v��` `t3 Z
No. Township Name 6r N�� Range No. Fire No.
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Conirador (Company Name)
a��1���_
,ddress (Con}m�oror Owner Performing Instollation)
Phone No. ��� �
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No. Mazter Lic. No. (Plant Eled. Only)
Auth rin Si nature ontrador or wner Performing ;tall 'on, ;�.� ��a Phone No.
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EB-OOOOlA-10 6/95 STATE BOARD COPY- SEE INSTRUCTIONS ON BACK OF YELLOW COPY
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