P - 84542p � � � � � � REQUEST FOR ELECTRICAL INSPECTION --
/� Minnesota State Board of Electricity
1821 Uni��ersity Ave., Rm. S-128, St. Paul, MN 55104
- Phone (612) 642-0800
` Home Duplex Apt. B�dg. Other: New Addn
Commercial Industrial Farm Remod Re air
Air Cond. Htg. Equip. Water Hh. 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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Calculate Inspection Fee - This Inspection Request will not be accepted without ihe 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 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TpTp� 5 U
Sign/Outline Ltg. Xfmr. � - —
Alarm/Remote Control
Swimming Pool
Irrigation Boom
$peCia� Insoestiow .�.
I hereby certify thaf I inspected the elechical installafion deuribed herein on fhe
Rougffln p,
� invesngativel�lE.t/ v tl� +� � _.� � j�` ��_��
4 T�H1S I_NSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
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OFFICE USE ONLY This request void 18 months from validation date printed in this box.
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PLEASE PRINT OR TYPE
Requesf Dafe . Rough-in inspecfion r uired2 ❑ Yes
��/ eq ❑ No Inspection Other Than RougMn: eady Now ❑ Will Call
CJ � �`(ou musf call fhe inspecfor when ready) Dafe Ready:
I, �licensed contractor ❑ owner hereby request inspection of the above electrical work at:
lob Address �Sheef, Box, or Route o.� City Zip Code
��f� S�%� � � � (--f i
iecfion No. Township Name or No. Range No. Fire No. Counw
Occupant
Power� �er
W��
Elechic�ha� (Company Name� / G
�_ ' _ _ ' "�-! C
1Aailing ddress (Conhactore ner Perfor�n�to
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4utho S�gnatu[e Contracfor or Owner Perform�
IA-i l 8/96
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IPhone No.
Address
Contrartor License No. �
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- SEE INSTRUCT10N3 ON BACK OF YELLOW COpY
Lic. No.
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