P - 81536REQUEST FOR cLECTRICAL INSPECTION
7.�i �- 614 Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �
_ Phone(612)642-0800
Home Duplex ApT. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re air
Air Cond. tg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above ►he work covered by this request. Enter remarks in this space and on the back of the white copy only.
Calculate Inspecfion Fee - This Inspecti
Other Fee
Mobile Home Park Stall
Street Ltg./Traffic Sig.
TransFormer/Generator
$ign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
i
Irriqation Boom
on Request will not be accepted without the correct fee:
# Service Entrance Size Fee # Circuits/Feeders Fee
0 to 200 Amps 0 to 100 Amps
Above 200 Am s Above 100 Amps
INSPECTOR'S USE ONLY TOTAL
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THIS INSTALLATION MAY BE ORDERED
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that I inspected the elechical installation described herein on the dates
DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 months from validation date prinfed in this box.
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PLEASE PRINT OR TYPE
Requesf Date Rou h-in ins ection re uired?
9 p q ❑ Yes No Inspection Other Thon Rough-In: Ready Now ❑ Will Call
�� � (You musf call the inspector when ready) Date Ready: � 7��
I, �licensed contractor ❑ owner hereby request inspection of the above electrical work at:
1ob Address (Sheet, Box, or Roufe No.) City , Zip Code
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$ecfion No. Township Name or No. Range No. Fire No. County
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Occupanf Phone No.
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Power Supplier Address
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Elechical Conhacfor �Company Name) Conhactor License No.
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Mailing Address �Conhactor or Owner Performing Installation)
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Aufhorized Signafure (Confracfor or Owner Performing Insfallafion) .
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Phone No.
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