P - 80753` REQUEST FOR ELECTRICAL INSPECTION
�'� V- 5 5 2 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. Water Htr. Load Mgmt. Other:
Dryer Range Efec. Heat Temp. Service
"X" a� ve the wo k covered by this reque t. Enter remarks in this space and on ihe back of ihe white cop on(y.
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Calculate Inspection Fee - This Inspection Request will not be accep►ed without the correct fee: �` w�
Other Fee # Service Entranc 'ze Fee # Circuitsf Feeders Fee
Mobile Home Park Stall 0 to 00 Amps 0 to 100 Amps
Street Ltg./Troffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR�s use oN�r T�AL O.0
SignjOutline Ltg. Xfmr. � JQ
Alarm/Remote Control
Swimming Pool
I hereb cerfi thal I ins ted the electrical insMllation described herein on the dates slafed
Irrigation Boom RoogMn pa�e
Special Inspect'
Final Da �
Investigative Fee �� -i--.
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MON S.
OFFICE USE ONLY This request void 18 months From validation date printed in this box.
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PLEASE PRINT OR TYPE
R ues` ate� _� Rough-in inspecfion requiredZ ❑ Yes �No Inspecfion Other Than Rough-In: ead Now ❑ Will Call
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I, �licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address Sheer, Box, or Ro No.) Ciy Zip Code
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Section No. Township Name or No. Range No. Fire No. County
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Power Supplier Address
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Electrical C hactor �Compony Name) onhactor License No. Masfer Lic. No. (Planf Elecf. Only)
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Mailing Address (Conhoct� r QwrAr PerForming Installafion�
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Aufhorized Sig afure (Conhacf or �te@r P o ing In ation) Phone No.
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EB-00001 A-1 1 8/96 • STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY