P - 83803REQUEST FOR ELECTRICAL INSPECTION �
/) !f� G v/� Q Q ° Minnesota State Board of Electricity 3
�I�1 p `t V � 1821 University Ave., Rm. S-128, St. Paul, MN 55104 � �
Phone (612) 642-0800 `'�''
ome Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re air
Air Cond. tg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders F e
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TO�A� �fl
Sign/Outline Ltg. Xfmr. � U
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ecfed the electrical installation described herein on }he dates stafed
Irrigation Boom Rough-In Dafe
$pecial Inspecti �-
Investigative Fe ��� ��---- a� '—
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WI IN 18 MONTHS.
OFFICE USE ONLY This request void 1 8 monfhs from validation date prinfed in this box.
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�k � 4 6 � 4 0 8 �* PLEASE PRINT OR TYPE
Requesf Date' � J Rough-in inspecfion required? ❑ Yes o Inspecfion Other Than Rough-In:
Q 'I
( �You must call the inspecfor when ready) Date Ready:
I, �icensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address �Street, Box, or Route No. City �
SS 3 3 �zn�is o �� c.
�qc �
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eady Now ❑ Will Call
Zip
Section No. Township Name or No. Range No. Fire No. County �� f�
K
Occupanf Phone No. A
t�o�' � .5�71-ogs
Power
Address
$�JUlCl2 �.EQC�'J1.�(,C
Mailing Address (Conhactor or Owner Performing Installation)
2114 wcr�sh�i.vtg�:an S� N.�.
Aufhorized SianaNre ICanfrador or Owner Performinq Insiallafion
EB-0OOOlA-11
�on}racior License No. I Masfer Lic. No. �Planf Elecf.
CQO����
� j I Phone No. I
1 7k1-6200
OF YELLOW COPY