P - 82174' REGIUEST FOR ELECTRICAL INSPECTION
O(� �) o� Q Q � Minnesota State Board of Electricity
0 4.d L J J 1821 University Ave., Rm. S-128, St. Paul, MN 55104
` Phone (612) 642-0800 "�'
Home Duplex Apt. Bldg. Oth��� � New Addn
Commercial Industrial Farm �i Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other: �
Dryer Range Elec. Heat Temp. Service �L �-� ��S brl ,���' ,
"X" above the work covered by this request. Enter remarks in this space and on the ack of the white copy, only.
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Calculate Inspection Fee - This Inspection 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 ,3 0 to 100 Amps .Q
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTA
SignfOutline ltg. Xfmr. �� rJ�
Alarm/Remote Conhol
Swimming Pool
I hereb certi ihat I ins ted the electrical insfallation described herein on the dates stafed
Irrigation Boo RougMn �.
Special Inspection ° � `, �a
Final Daf� �f/,� An,
Investigative Fee / —«
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 monfhs from validation date printed in this box.
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PLEASE PRINT OR TYPE
Reques �a ^�� Rou h-in ins fion r uired?
� ,g pec eq ' ❑ Yes No Inspection Other Thon Rough-In: ❑ Ready Now � Will Call .
7 (You must call the inspector when ready) Date Ready:
I, ❑ licensed contractor owner hereby request inspection of the above electrical work at:
1ob Addre �Sheet, � or Roufe o.J„� � � Ciy � � Zip C�
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Secfion No. Township Name o. Range No. Fire No. ounty
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Occupant � Phone No.
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Power Supplier ' , ,� / � (� O � AS�reu �N� LI � ^
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Eleclrical Conhactor (Company Name) � Contractor License No. Masfer Lic. No. (Plant Elecf. Only� �
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Mailirg Address (Contraclor or Owner PerForming Installafio � .
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Authorized Signa ontracfor or Owner Pe afion) Phone No.
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E&OOOOIA-11 8/96 STATE B RD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY