P - 81079.� REQUEST FOR ELECTRICAL INSPECTION
"7 �'� �(1 (� 3 � Minnesota State Board of Electricity ;
p � �,J e.J 1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
Home Duplex Apt. Bld . Other. ��L a�r�q �_ New Addn
Commercial Industrial Farm � J Remod Re air
Air Cond. Ht . Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Terrlp. Service
"X" above fhe work corered y this jequest. nter remarks in this space and on Ihe back of the wh+ie copy only.
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Calculate Inspection Fee - TSis Inspection Request will not be accepied withoui the correct fee:
Other Fee # Service Entrance Size # Circuits/Feeders
Mobile Home Park Stol! 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Ar
Transformer/Generaror INSPECTOR'S USE ONLY TOT�
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
1 hereb certi thot I ins ted the eleckical
Irrigation Boom Ro„9�,�„
c�y, �D
descri6ed herein on the dates stafed
Dafe
Investigative Fee �� � �;Z,� �<�-�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
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OFFICE USE ONLY This request void 18 months From validafior date prinled in fhis box.
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PLEASE PRINT OR TYPE
Request Date Rough-in inspection required? ❑ Yes o Inspecfion OFher Thon RougMrc ❑ Ready No ill Call
�You musf call the inspecfor when ready) Dafe Reody:
I, icensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Addr-ss (Skeef,iox, or; ute No.) n City� - �/ Zip Code
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Secfion No. Township Name or No. Range No. Fire No. Coylily
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Occupanf � Phone No.
,���.� N.��S o 7�d - �� �
Power Supplier A dress
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A-11
:tor ( mpany Name� C/on^hacto/� License No. Master Lic. No
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�Conhactor or j�wner P rformi Insfallafion)
r�! G� t Li � -✓'G� hcr .$ c�C� d
Owner Perf min stallation) 1 �' Phone No.
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY