P - 84686REQUEST FOR ELECTRICAL INSPECTION >° �.
5 0 fl �(] 0 O Minnesota State Board of Electricity
�-j` J 1821 University Ave., Rm. S-128, St. Paul, MN 55104
; Phone (612) 642-0800
Home Duplex Apt. Bldg. Other: New Addn
ommercial industrial Farm Remod Re ir
Air Cond. Htg. Equip. Wafer Hh. Load Mgmt. Other:
D er Range Elec. Heat Temp. Service
"X" above the work covered by ihis request Enier remarks in �his space and on the back of the white copy only.
�n� �� G��h� Cc�
Calculate Inspeciion Fee - This Ins ,
Other Fee
Mobile Home Park Stall
Street Ltg./Traffic Sig.
Transformer/Generator
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
Irriqation Boom
m Request will not be accepted withouf the correct fee:
# Service Entrance Size Fee # Circuits/feeders
0 to 200 Amps 0 to 100 Amps
Above 200 Am s Above 100 Amps
INSPECTOR'S USE ONLY TOTAL �
I hereby certi(y fhat I inspetled fhe elechical installafion described herein on the dafes sfated
Rough-In pa�¢
Inveshgahve hflV v �I V —� — -�� -^Y�D,'
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months (rom validaticn date printed in this box.
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* O.5 O D 9 O O Ia �IC PLEASE PRINT OR TYPE
Request Dafe _� Rou h-in ins fion r uired$ ❑ Yes
g pec eq ❑ No Inspection O�er Than RougMn: eody Now � Will Call
(You musl call fhe inspeclor when ready) Dale Ready:
f, censed conhactor ❑ owner hereby request inspection of the above elecfrical work at:
1ob Addreu (Sheef„Bo�r, or Roufes�JQ.) /� _ Cityf) . � , Zip Code
iip Name or No. Ra
Ad
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Com any Nome� �
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fra or Owner P rForming Installa ion�r
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(Conhacior or Owner P� rm' g InsfallaK�
Phone No.
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anse No. Master Lic. No. (Planf Elect.
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