P - 80727������ �� ��I (� I�� �� �� ' ' ` � REGIUEST FOR ELECTRICAL INSPECTION
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Minnesota State Board of Electricity � ��
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �= �
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Home Duplex Apt. Bldg. Other: ..Q+�✓ a�?'� � New Addn
Commercial Industrial Farm Sm o,� �„y�'�S` °�' r'P Q� h Remod Re air
Air Cond. Htg. Equip. Water Htc Load Mgmt. Other: �����.����
D er Ran e Elec. Heat Tem . Service
"k' ab ve the work covered by this request. Enter remarks in this space and on the of the white copy only.
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Colculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:/
Olher Fee � Service Entrance Sae Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Lig./Tra$ic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR�suseoN�v TOTAL��
Sign/OutlineLtg.Xfmr. Nh,L/L�/rcj —_
Alarm/Remote Control
$wimming Pool
I hereb certi that I ins eded the eledrical insTallafion described herein on 1he dates stafed
Irrigation Boom . Rough-In Date
Special Inspecti
Investigative Fee "��� ���-/-ti� vZ
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
3� 7- 5 8 4 OFFiCE USE ONLY This roquest void 18 monlhs from validafion da nted in this box.
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PLEASE PRINT OR TYPE
Requasi e � Rough-in inspeclion req�ired2 ❑ Yes No Inspeclion Other Than Rough-In: � Ready Now Will Call
a39 ('!ou must wll the inspedor when ready) Dote Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sireet, Box, or Ro No.) City Zip Code �
[o/a Gvem� Lah.� �'v.;cQl.e 5'.S 3 Z
$ection No. Township Name o o. Range No. Fire No. Co ty �� /_A
Gl .�C.
Omupant - Phone No.
�,�-� �a���.sa � ��3� g� -007�
Power Supplier � � � P,ddress
EI�cal Co traq�r (Com ny Nome) � _ Confracro� cense No. Masier Lic. No. (Plant Elect. Only)
4 ff�'Q�6 r' L�,r� � C. C�- � %
Mailing Address (Cont r or Owner Performing InsTallafion) � ���r
1�u w� .s�� S. f� ��t�l Ol�.ec�i� /h �
Au orized Sign re(Contrador or ner Ped ing �ns fi n) . Phone_No.�/� —��
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