P - 81548REQUEST FOR ELECTRICAL INSPECTION
Q�'r ��� Z� Z � Minnesota State Board of Electricity
V�� 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. Ot a_,��
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.
Calculate inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance ' e # Circuits/Feeders Pee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps J�0"`
Street Ltg./Traffic Sig. Above 200 m s Above 100 mps
Transformer/Generator INSPECTOR•s use oN�v T�L l S�
Sign/Outline Ltg. Xfmr. � �
Alarm/Remote Control /�
Swimming Pool �(, � �� �/ —�/!�'�'�/�
I hereb certi that I ins fhe ical ins Ilafion described herein n e s
Irrigation Rougl�ln
SpeciallnspecSion' '" �
Final a
Investigative Fee i /�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHI 1 ONTHS.
OFFICE USE ONLY This requesf void 18 monfhs 6om validafion dafe prinfed in this box.
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PLEASE PRINT OR TYPE
Req est Date �� R h-in ins tion r uired2 Yes
oug pec eq ❑ No Inspeclion Other Than Rough-In: ❑ Ready Now ilf Calt
�V �ii�o (You musf call the inspector when ready� Dafe Ready:
I, ❑ licensed contractor owner hereby request inspection of the above elecfrical work at:
Job Address (Street, Box, or Route No.) Ciy � Zip Cod
1 O�� �..t p�.���e.� � 2 �ip �� 2..
Secfion No. Township Name or � ' . . Range No. , Fire No. Coun
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( panf 1�. � `��:..�� �6,3 ��� ^ � �q �
Power upplier . Addre � ' �q
� t_ I E� �'� //�,/b l�%l�� e�.�
Elechical Conha ompany Name� � v� Conhacror License No. Master Lic. No. �Plant Elect. Only)
Mailing � c�lrq� nha r n�t i g i all ' J � ��� `_�^ L�
� V �.t � �+ 7
uthori ed Sign ur (Con r ner Performing Installation� hone
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E OOIA-11 8/96 STATE BOARD C Y- SEE INSTRUCTIONS ON BACK OF YELLOW CO