P - 83647REQUEST FOR ELECTRICAL INSPECTION
/� %� �%�� Minnesota State Board of Electricity
`� •� � 1821 University Ave., Rm. S-128, St. Paul, MN 55104
r• Phone (612) 642-0800
Home Duplex Apt. Bldg. Other: New
Commercial Industrial Farm Remod
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ir Co . Htg. 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 ihe back of the white copy only.
C�.�. �' ,� Ic� �
Calculate Inspection Fee - This Inspection Request will not be accepted ,vithout the correct 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 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Outline Ltg. Xfmr. �.
Alarm/Remote Control
Swimming Pool
. I hereb certi that I ins ected the electrical installation described herein on the dates stated
Irrigation Boom Rough-In Dare
Specia� Inspectio � , . _ _
Imestigative fee J ' T /
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
� OFFICE USE ONLY This requesf void 18 monfhs from validafion dafe prinfed in this box. '�
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* O 4 7 6? 3� 5� PLEASE PRINT OR TYPE �� �
Request Date � Rough-in inspecfion required? ❑ Yes ��AJo Inspecfion Ofher Than Rough-In: ❑ Ready Now�Will Call
g-� �-" l� (You must call the inspector when ready� Date Ready: �J, ��_� `
I, �licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Street, Box, or Route No.) City Zip Code
`7501 (.�ni ver.si�- ��E. /v � �j��v��Y ���32
Section No. Township Name or No. Range No. Fire No. County
Occupanf
erle �a ►-d
Power Supplier Ad �
Elecfrical Contractor (Company Name
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Mailing Address (Confractor or Owner Performing Insfallafior�
5'�l�sa��� �. //�l,
Authori ' a u �ontractor or - erN�rminEllns Ilation
Contracfor License
Phone No. _�
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Lia No.
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PhoHne No.
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