P - 82957��
REQUEST FOR ELECTRICAL INSPECTION =�
���^ QQ Minnesota State Board of Electricity -
C� V V� � 1821 University Ave., Rm. S-128, St. Paul, MN 55104 �
` Phone (612) 642-0800 "°�'
Home uplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re ir
Air Cond. i. Htg. Equip. Water Htr. Load Mgmt. Other:
�- Dryer�,�%, s Range "�° Elec. Heat Temp. Service
„X" above the work cavered by this requesl. Enter remarks in this space and on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted wifhout the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Homel�ark StaA� 0 to 00 Amps �'�o0 0 to 100 Amps " (�.�5
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY � o �,_-,± ��. �� TOTAL
Sign/Outline ltg. Xfmr. ' �-"�'�—r �" � �-'� `'` t� � b � �
Alarm/Remote Control �� �'' ��
Swimming Pool
I hereb certi thai'I ins ted the eleckical ' afiop described herein on da�es sfaAed
Irrigation Boom Rough-In , _ f � � '�
Speciallns , �� .��.�---�'�(c
Investigative ee '
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THIS INSTALLATION MAY BE ORDERED DIS NNECTED IF NOT COMPLETED WITHtN 18 MONTHS.
_ -- — — -- — ---�--
�� � OFFICE USE ONLY Thia request void 18 months hom validafion date printed in this boz.
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* � 4 3 � 8 8 2 4�K PLEASE PRINT OR TYPE
Requesf Da Rough-in inspeclion required? ❑ Yes ❑ No Inspecfion Olher Than RagMn: ❑ Ready Now 0�II Call
� � ��`% �`fou must col{ the inspecior when ready) Date Reody:
I, icensed contractor ❑ owner hereby request inspection of the above elechical work ah
Job Address (Sheet, Box, or Route No.) Ciy � Zi Co�
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Secfion No. Township Name or No. Range No. fire No. County .
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�sua�-. o w„�-�s.- LC /�lf�, w,o� No.
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Power Supplier Addres �
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Elechicnl ConhxMr (Company Name) Confractor License No. Masfer Lic. Mo. �Plant Elect. Onh�
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Mailing Addreu �Conhacfor or Owner Performing Installafion�
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Autfwri Signalure (Confracfor a Owner P � II � � Phone No.
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E&00001 A•11 96 �p� gpppD COPY - SEE INSTRUCTIONS ON BACK OF YEf10W COPY