P - 83501RE(�UEST FOR ELECTRICAL INSPECTION
5 7 0�= O� O Minnesota State Board of Electricity -
1821 Universiiy Ave., Rm. S-128, St. Paul, MN 55104
` � Phone(612)642-0800
Home Duplex Apt. Bldg. Other: New Addn
Commercial Indusfrial Farm Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat ;.Temp. Service
"X" above the work covered by this request. Enter re arks in this space and on the back of the whiie copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepfed without the correct fee:
Other Fee # Service E trance ' e Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 t 200 mps 0 to 100 Amps ��
, Street Lt ./Traffic Si . Above 200 Amps Above 100 Amps
9 9
Transformer/Generator iNSPeCroR'S USE ONLY TOT L�
$ign/Oudine Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
I hereb certi ihat I ins ted the electrical installation described herein on the dates stoted
Irrigati�n Boorrf , �� RougMln Date
Special Inspection
Final
Investigative Fee j Z3—
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WI HIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 monfhs from validafion dafe prinied in fhis box.
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* � 5 7 � 8 2 8 �I �R PLEASE PRINT OR TYPE
Request Dafe Rough-in inspeciion required? ❑ Yes ��o Inspecfion Ofher Than Rough�ln: ❑ Ready Now ill Call
�>r � (You must call fhe inspeclor 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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Secfion No. Township Name or No. Range No. Fire No. County
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EI �`� al onhacWr (Company Name� �� �� „ � �- Contracfor icense No. . � Masfe� Lic: No. (Planf Elecl. Only) �
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Mailing Address (Conhacror or Owner PerFo 'ng Installation)
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Authorized g Nre �ConhacFor or er Pe rming Insfal 'on� `) �, �p Phone No.
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E OOIA-1 1 8/96 STATE A D COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY 75'j C�3