P - 828185�2°517 =�-
Home Duplex
Commercial Industrial
Air Cond. Htg. EqJ
Dryer Range
"X" above the work covered 6
REGIUEST FOR ELECTRICAL INSPECTION �= .
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0,g0 `
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Apt. Bldg. Other: ,.-� �I New Addn
Farm `� Remod Re air
Water Hh. Load Mgmt. Other:
Elec. Heat Temp. Service
request. Enter remarks in this space and on the back of the whiie copy only.
Calculate Inspection Fee - This Inspection Request will not be accepted wifhout the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 ro 100 Amps
Street Ltg./Traffic $ig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S U$E ONLY ; TOTAL � S�
Sign/Oudine Ltg. Xfmr. /� .�� �
Alarm/Remote Control �
Swimming Pool ��� � 7� �`���
I hereb certi Ihat I ins the electrical inslallafion descn on da�es sfalad
Irriaation Boom o,.....i.,.. n.� ._ .rv
� Investigative Fee �`� f-� �7 � � �(/ � U� L��'
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE I�E ONLY This request void 18 months fran validation dale printed in ihis box.
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IIIIIIIIIIIIIIIIIIIII Illlllllllllllllililil �7s
* 0 5 3 2 5 L� �* pLEASE PRINT OR TYPE
Request Date Rough-in inspection required? ❑ Yes
/ ❑ No Inspection O�er Than RougMn: ❑ Ready Now � WiN Call
�— i l' g(� (You must call the inspecfor when ready) Date Ready:
I, ❑ licensed contractor �wner hereby request inspection of the above elechical work ah
.� naa� �s�f, �X, or Route No.) Ciy Zip Code
�� �� a � �� st N� -��d 1-� ��42
Section No. Township Name or No. Range No. Fire No. Couniy/� �
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Power Supplier Address
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Electrical Contractor (Company Name) Contraclor license No. AAasFer Lic. No. �Plnnt Elecf. Only�
Mailing Address (Conhaclor or Owner Performing Installafion�
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� Insfallalion . �J (J � Plrone �.
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COPY - SEE INSTRUC770NS ON BACK OF YELLOW COPY