P - 83436REQUEST FOR ELECTRICAL INSPECTION
6��.2+�`t `t � Minnesota State Board of Electriciry a
� 1821 University Ave., Rm. S-128, St. Paul, MN 55104 �
Phone (612) 642-0800 `'�'
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 the back of the white copy only.
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Calculate Inspection Fee - This Inspection Requesf will noi be accepied 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
Transformer/Generator INSPECTOR'S USE ONLY TOT/j�! ��
Sign/Outline Ltg. Xfmr. l
Alarm/Remote Control
Swimming Pool
I hereb certi thaf I ins the elechical installafion described herein on the dates stated
Irrigation Boom Rough-In Dore
Special Inspe ' �
Investigative F�oa1 ^ Z6,
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONL� This requesf void 18 monfhs from validafion date printed in this box.
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PLEASE PRINT OR TYPE
Requesf D Rough-in inspection required? ❑ Yes o� Inspection Other Than Rough-In: ❑ Ready Will Call
` 'ZZ Q� (You must call fhe inspeclor when ready Date Ready:
1, �icensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sheet, Box, or Route No.� City Zip Code
7 S` G��T �cc �ld�G� s� 2
Section No. Township Name or No. Range No. Fi�e No. County
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Occupanf / Phone No. �
i1��.1%/ N/ /! 1/ /�. /Jr� ��/��
ny Name) Conhactor License No. Master Lic. No. �Phnt EIeM. Only)
�i G?/f�'t v/3
or Owner Performing Installafion)
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icror or Owner Performing Installafion) Phone No.
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY