P - 79721REQUEST FOFi ELECTRICAL INSPECT{ON
Q(� ���� Q � Minnesota State Board of Electricity
ts �1 v 1821 University Ave., Rm. S-128, St. Paul, MN 55104
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Phone (612) 642-OS00 "�`
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial 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 remarks in this space and on Ihe back of the white copy only.
Calculate Inspection Fee - This Inspecfion Request will rot be accepied withovi the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Sheet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAI
Sign/Oudine Ltg. Xfmr. ��• `S�
Alarm/Remote Control
Swimming Pool
certi that I ins the elechical installafion described herein on the dates stated
Irri ation B Ro�yM� o
Special Ins n �� � �'
rll�T /' / �°re r p3
Investigative Fee X i'� L d �l "�
THIS INSTALLATION MAY BE ORDERED DISCONNECTE IF NOT COMPLETED WITHIN 18 MONTHS.
OfFICE USE ONLY This rnquesf wid 18 months from validation date prinfed in this box.
I lifl II i1111 III II III II III II III II III If III II � i�I
* U 8❑ 2 2 9 8 0* �*'`�''�' ,�Q.so
PLEASE PRINT OR TYPE
Request Dafe Rouglrin inspeclion required? Yes ❑ No Inspecfion Other Than Rough-In: ❑ Ready Now Will Coll
��� ��� �`(ou must coll the inspecfor whe ready) �Dafe Ready:
I, ❑ licensed conhactor �owner hereby request inspection of the above electrical work at:
lob Ad �(� Bo , or R�� o � �� � City � �,L. Z� V�� ��
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Secfion No. Township Name or N Ronge No. Fire No. C
�.3v a �
Occupant Phone No.
' �c� -rt^ �,.p j%, � � �r%1- '���.
Power Supplier Address 1
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Eleclrical Conkacfor (C��pny Name) Contracfor License No. Master Lic. No. �Planf Elect. Only)
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1 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY