P - 83483� REQUEST FOR ELECTRIC�4L IN�DECTION
6��� r 3 O Minnesota State Board of Electricity .
0 1821 University Ave., Rm. S-128, St. Paul, MN 55104
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Phone (612) 642-0800
Home Duplex Apt. Bldg. Other: N
� Commercial Industrial Farm Re
Air Cond Htg. Equip. Water Htr. Load Mgmt. Other.
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 c
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Cakulate Inspection Fee - This Inspection Request will not be accepted without ihe correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY T TAL
Sign/Outline ltg. Xfmr. �S -
Alarm/Remote Control
Swimming Pool
I hereb certi thaf I ins ected fhe elecfrical installation described herein on the dafes sfated
Irriqation Boom Ro�o1.i� Dare
Fee
Investigative F �� Final // ` I[�, Z� S'a/
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THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPIETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request wid 18 months kom validation date printed in this box.
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PLEASE PRINT OR TYPE
Request Date Rough-in inspection required? ❑ Yes Inspection Other Than Rough-In� dy Now
�� (You musf call the inspector when ready) Date Ready: .
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
lob Address �Sheef, Box, or Roufe No.) City Zip Code
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Section No. Township Nome or No. Range No. Fire No. Coun
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Power Supplier - Address
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Elechical Conhactor (Company Name)
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Mailing Address (Conhacfor or Owner erforming Insfallation)
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AWhorized $ianahire 1Gon for or Ow�ur Performin n a' n�_�
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Phone No.
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ON BACK OF YELLOW COPY
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