P - 83276REQUEST FOR ELECTRICAL INSPECTION °�
5 3'G - 5 2 8 Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612) 2-0800
' Home Duplex Apt. Bldg. Other: New Ad
Commercial Indushial Farm � Remod e air
Air Cond. Htg. Equip. Water Hfr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this requesf. 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 ►he correct fee:
Other Fee # Service Entrance Size Fee # Cirwits/Feeders Fee
Mobile Home Park Stall 0 ro 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOT
Sign/Oudine Ltg. Xfinr. i �
` � Alarm/Remote Conhol
$Wimmin9 Poo� I herebvi certiH tfwf I insoecled the electrical installation described herein on the dales alaled
Special Inspection — U --" O
Pind
Investigative Fee /^ �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 1 MONTHS.
_ OFFICE USE ONLY This request void 18 months from wlidation date printed in Ihis box.
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* � 5 3 2 5 2 8 7�k PLEASE PRINT OR TYPE
R�1�gt �O� �� . Rou h-in ins on r uired$ Yes
g pecfi eq ❑ No Inspection Other Than RougMn: ❑ Ready Now Will Call
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�You must call the inspector when ready) Date Ready:
I, ❑ licensed contractor �owner hereby request inspecfion of the above electrical work at:
Job Address (Sheet, Bou, or Rou�e No. Ciy � � � Zip Code �
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Seclion No. Township Name or No� Ra � o. Fire No. Couny`��1
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Occupanf Phone No. ���� �� � � � �
LGS<,4.�. '��
Power Supplier ^ Add �� t
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Elechiml Conhaclor (C y Name) Conhactor License No. Masfer L"ic. No. (Planf Elect. Only� �:,
V�.�/
. Mailing Address (ContractoyerOwner Performing Installation) .
or Pertorming I Uafion� ��� . i) /7 � . Phone No.
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STATE BOARD CO - SEE INSTRUCTIONS ON BACK OF YELLOW COPY