P - 84713-` . REGIUEST FOR ELECTRICAL INSPECTION -
4 9 5- 3 8 9 Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800
Home Duplex Apt. Bld . Other: New Addn
Commercial ndushial Farm Remod Re air
Air Co Htg. Equip. Water Htr. Load Mgmt. er: - - �
Dryer Range Elec. Heat Temp. Service �(�'C
"X" abo`/ve,�th-e w�jork covered by ►his request. Enter remarks in ihis space an on the bac of the iie copy only.
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Calculate Inspection Fee - This Inspecfion Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Sfreet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ON�Y TOTAL
Sign/Oudine Ltg. Xfmr. lY� Z'� �7 �
Alarm/Remote Control
Swimming Pool
I hereb certi that i ins the eleclrical installation described herein on the dates slated
Irrigafion Boom Rough-In pa�
Investigative Fee — ���
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This requesf void 18 months 6om validafion date printed in this box.
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* 0 4 9 5 3 8 9 9* PLEASE PRINT OR TYPE
Request � ate Rough-in inspecfion required2 ❑ Yes o Inspecfion Olf�er Than Roug n: eady Now ❑ Will Call
C(You must call the inspeclor when ready) Date Ready: � i I
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address �Sheef, Box, or Route No.) � Zip Code
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Seciion No. Township Name or No. Range No. Fire No. County
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Conhactor (Company Name) _�, _" -� CoNwcla License No. _ _ Nlasler Lic. No. IPlant Elect.
or
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STATE BOARD COPY - SEE INSTAUCTIONS ON BACK OF vEUew coav