P - 83856REQUEST FOR ELECTRICAL INSPECTION --
4,(� Z� O O Q 0 Minnesota State Board of Electricity
O �J ° 1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800 ^ ' `ffi'
Home Duplex Apt. Bldg. Other: New dn
Commercial Industrial Form Remod Re ai
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 the back of the white copy only.
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Calculate Inspeciion Fee - This Inspection Request will not be occepted 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
Streef Ltg./TrafFic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Outline Ltg. Xfmr. ��.s�
Alarm/Remote Control
Swimming Pool
I hereb certi that I inspected the electrical installation described herein on the dotes stated
Irrigation Boom M Rough-In Date
Speciallnspec' �j =t
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Final v
Investigative Fee ..�__--------�--- �/'
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 11fiONTHS.
OFFICE USE ONLY This request vold 18 monfhs (rom validafion date printed in this box.
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Request Date Rough-in inspection required? ❑ Yes �No Inspection Other Than Rough-In: Ready Now ❑ Will Call
(� _��p ,�/' (You must call fhe inspector when ready) Date Ready:
I,�licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address �Streef, Box, or Route No.) City Zip Code
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Section No. Township Name or No. Range No. Fire No. un ^
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Power Supplier
Elec}rical Conhactor (Company Mame) �
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Mailing A dress ( r�hactor or wner P rf�
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A S'� atur ahactor or Owner
B-00 Ol A- 1 S 96 ATI
Conhactor License Na
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Phone No.
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Lic. No.
Phone No.
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