P - 84449IIIIIIM�IIIIIIIIIIIIIIIIIIIII IIIIIII�II REGIUEST FOR ELECTRICAL INSPECTION �,
II I I�II Minnesota State Board of Electricity �
1821 University Ave., Rm. S-128, St. Paul, MN 55104 ,_ �'
�`0 2 9 9 3 4 B 3 * Phone (612) 642-0800
Home Duplex Apt. Bldg. Other. NP,,,, Qaa„
C:ommercial Industrial Farm
Air Cond. Htg. Equip. Woter Htr. Load Mgmt. Other: L� �} ��/TS'
D er Ran e Elec. Heat Tem . Service �( Gt � j!V �
"X" above the work covered by this request. Enter remarks in this space ond on the back of fhe
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copy only.
Colculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Olher Fee #E $ervice Enirance Size Fee # Circuits/Feeders
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic $ig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'SUSEONLY TOTA
$ign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
I hereb certi ihaf I ins ecfed }he eledric I insfallation described herein on the dates stated
Irrigdtion Boom Rough-ln Dat �
Special Inspedion � �}
Investigative Fee �� ,`�^ Dare�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 1 MO
2 9 9- 3 4 8� OFFICE USE ONLY This request void 18 months from validation date printed in this box.
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Fee
PLEASE PRINT OR TYPE
Request Date Rough-in inspection required2 � Yes � No Inspedion Ofher Than Rough-In: Q Ready Now � Wi�� Call
� �� �% (You must call fhe inspecfor when ready) Dafe Ready:
I, ❑ licensed contractor � owner hereby request inspection of the above electrical work at:
Job Address (Street, Box, or Route No.) City Zip Code
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$etfion No. Township Name or No. Range No. Fire No. Counly
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r $upplier Address
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iwl Confrador (Company Name) Confracfor License No
Address (Confractor or Owner Perfortning Installafion)
IAuthorized $ignature (Confrador or Owner Performing Installafion)
Phone No.
.S 7�-�fl� 9
Master,,L,/ic. No. (Pdant EIecY. Only)
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Phone No.
EB- 0 6/95 STATE BOARD COPY- SEE INSTRUCTIONS ON BACK OF YELLOW COPY