P - 83932��1-656 _aa
Home Duplex
RE(�UEST FOR ELECTRICAL INSPECTION %�_�.
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800
Other: � New Addn
Commercial Industrial Form /� C� Remod Repair
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
copy
Calculate Inspection Fee - This Inspection Request will not be accepied wifhout fhe 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 TOTAL q�
Sign/Outline Ltg. Xfmr. �� 1`^-�
Alarm/Remote Control
Swimming Pool
1 hereb certi thaf I ins ihe elechical insfallafion described herein on the dates stated
Irrigation Boom Rougffln par�
Special Inspecti
Final D
Investigative Fe .- 5'�-
THIS INSTALLATION MAY BE ORDERED D NECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This request void 18 monfhs from validafion dafe prinfed in this bo(C.
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I IIII II II) II III II III II II� II �I II III II III I IIII �
* � 5 3 L 6 8 6�} * PLEASE PRINT OR TYPE ��
Requesf Dale Rough-in inspecfion required? ❑ Yes Inspecfion Olher Tha Roug n: Ready Now ❑ Will Call
(You musf call the inspecfor when ready) Dafe Ready: �� 3
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job ddress �Sheef, Box, or Roufe City Zip C
3 g� �-� �e ;�S—�3 �
Secfi n No. Township Name or No. Range No. Fire No. County ` � I„ „
N r ��
Occupanf Phone No.
�iSe,���O�L� ►'� �- � J %z �
Pow r Supplier Address
� � I �.5 '�, i n��e �, � ) ` �C/�% .3
lechical Con ractor (Company Name) Conhacfor License No. Master Lic. No. (Plant Elect. Only
�C. �G�1 �'Li� �
, Mai �g Address onhactor or Own PerForming Installation� /.�� ^�
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