P - 82978REQUEST FOR ELECTRICAL INSPECTION
5 5. v`�.J � m 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
Commercial Industrial Farm Remod Re air
Air Cond. Htg. Equip. Woter Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
„X„ above the work covered by this request. Enter remorks in this space and on the back of the white copy only.
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Calculafe Inspection Fee - This Inspection Request will not be accepied without the correcF fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders F
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�L�
Sign/Oudine Ltg. Xfmr. � �
Alarm/Remote Control
Swimming Pool
I here certi Ihat I ins fhe elechical insMllafion deuribed herein on the dates sfafed �
Irriaation Boom vti�.�,., n..b
apeciai ins ■-
Firwl �?
Investigative —
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WIT IN 1 MONTHS.
OFRCE USE ONLY This roqueat void 1 s 6om validafion date printed in this box.
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* 0 5 5 9 3 9 6 7* �EqSE PRINT OR TYPE
Reques te RougMin inspecfion required$ ❑ Yes No Inspeclion Other Than RougMn: Ready Now ❑ Will Call
C� (You must call Ihe inspe�ior when ready) Dafe Ready: 3
I, licensed conhactor ❑ owner hereby request inspection of the above electrical wor at:
� Job Address �Sheet, Box, w Rouae No.� Cily ` Zip Code
ysa C��;�d ��� � �
Seclion No. Township Name or No. Range No. Fire No. ounly
Occupant
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Power Supplier Address
Eleclrical Con r (Company Name
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Mailing ,4ddre (Conhacroe or Owner Perfonning Inslallafion) �
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Authwized igna (Con r or Performing Installati )
E&00001 - 1 8/96 y�ATE B D COPY - SEE II
Phone No.
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Contractor license No. Master Lic. No. (Want E�ec
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kwne No.
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T10NS ON BACK OF YELLOW COPY