P - 83302, REQUEST FOR ELECTRICAL INSPECTION °"
6 9.1-12 0� Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �`
� Phone (612) 642-0800 ''°�'
Home Duplex Apt. Bldg. Other: New Addn
mmercipl Industrial Farm Remod Re air
Air Cond. Hig. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heaf Temp. Service
"X" above the work covered by this request. Enter emarks in this space and on the back of the white copy only.
lG� d�,o �'�
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Trpnsformer/Generator NYSPECTOR'S USE ONLY TOTA���
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ted the electrical installation described herein on the dates sMfed
Irrigation Boom Rough-In Date
Speciallnsp i
Finol
Investigative
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WIT N 18 MONTHS.
OFFICE USE ONLY This �equest void 18 monihs from validation dafe printed in this box. �
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* 0 6 9 1 1 2 0 0* �
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P ASE PRINT OR TYPE
Request Date�:�/` ..� i� Rough-in inspecfion requi�ed? ❑ Yes No Inspecfion Other T}wn Rough-In: eady Now � Will Call .
� ��� (`(ou musf call the inspecfor when ready Date Ready:
I, icensed contractor ❑ owner hereby request inspection of the a ve electrical work ai:
Jo ss Sheef Box, or Rou No.� Ciy Zip Code �
� , G'�� e- � � t°
Section No. Township Name or No. Range No. Fire No. unly
�V
Occupant � � Phone No.
Q'/1 / a��o� �.S'
Power Sup li Address
�' �/� � f%''�o � .
Elechi r(Com n ame) Con cror Licen No. Master lic. No. (Plant Eled. Only)
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` �Q' ��"d.�
ilipg 1�ldress �Conha Ownel Performing Insfall � � � �� /�
�.....�, ,,, �?�5�9 � ���—l�D.�
BOARD COPY - SE ,,, � BACK OF YELLOW COPY