P - 80357REQUEST FOR ELECTRICAL INSPECTION °'�
Q('f� �'j Q� � Minnesota State Board of Electricity a
CI V 1. V 1821 University Ave., Rm. S-128, St. Paul, MN 55104
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` Phone (612) 642-0800 '��'
Home Duplex Aot. Bldq. Other: New Addn
Commercial Industrial Farm Remod Re air
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 copy only.
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Calculaie Inspection Fee - This Inspection Request will r,oi be accepted withoui the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
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 TOT���
Sian/Outline Lta. Xfmr.
� Pool
I hereby certify that I inspected the eleclrical installation described herein on the dares stated
BOOm_ RougMn � ���_ Date�r i
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� Imestigative Fee '� ��i � � ..— � , � 'et /–� —m (
THIS INSTALLA'f10N MAY BE ORDERED DISCONNECTED IF NOT C0IIIPLETED WITHIN 18 MONTHS.
OFFICE U8E ONLY This roquest void 18 months Irom validation date printed in fhis box.
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PLEASE PRINT OR TYPE
Request D te Rough-in inspecKon required$ es ❑ No � Inspection Other Than RougMn:
(You mus� call the inspecror w en ready) Date Ready: �
I, icensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address �Sfreef, Box, or Route No.� Ciiy
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Section No. Townshi Name or N Range No.� Fire No. Cou� j^ _
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O t Phone No
Now ❑ Will Call
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ccupan .%/"G.i - " ` C � L� G\�c1J l � ( � �� �N ��7 � Q �
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PowerSupplier , /� q Address/j _ _
Eleclrical CoC� mpan�me)
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Mailing Address (Conhoctor or Owner
Authorized SS'yqpj�j C/6n� or Owner Perfurming
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BOARO COPY - S INSTRUCTIONS ON
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License No. Master Lic. No. �Plant Elecl. Onl;
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Phone No.
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