P - 82783RE(IUEST FOR ELECTRICAL INSPECTION
5��= 6 21 Minnesota State Board of Electriciry
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. Htg. Equip. Water Htr. Load Mgmt. Oiher:
Dryer Range Elec. Heat Temp. Service
"X" above fhe work covered by this request. Enter remarks in ihis space and on the back of the white copy only.
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Calculate Inspecfion Fee - This Inspection Request will not be occepted without the correci %e:
Other Pee # Service Entrance Size Fee Circuits/Feeders Fee
Mobile Home Park Stall to 00 Amps .(� 0 to 100 Amps -�
Street Ltg./Traffic $ig. Above 200 Amps Ai�ove 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TO� �
$ign/Outline Ltg. Xfmr. �—
Alarm/Remote Confrol
Swimming Pool i he certi that I ins the eleclrirnl insrollation described herein on 1he dotes sMted
Irrigation Boo -r ; RougMn �
Special Ins ' rt-- `.%
Fmd a�
Investigative Fee
THIS INSTALLATION MAY BE ORDE�tED DISC CTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This roqueaf vad 18 months (rom wlidafion date printed in this box.
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* O S 2 3 6 �L L 1 7ic PLEASE PRINT OR TYPE
Re9�n � Q Rough-in inspection required? ❑ Yes Inspeclion Olher Than RougMn: ❑ Ready Now i Call
� 2� ^`� (You must call the inspec�or when ready) Date Ready: -
I, icensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Addreu (Sheet, Box, or Rou�e No. � City Zip Code
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Seclion No. Township Namg�r No. Rang� . Fire No. ounty �
�t ��e1 �
Occupant Piane No.
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Power Suppli Address
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Elechiwl Conhacior (Company Name) Contracror li�nse No. Mas1e� lic. No. �Plant Elect. Only)
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Mailing Address (Conhacror or Owner Performing Installafion) � �
�30 �e � �c .�/' �3�YZ--
Authorized Si n re � nhacro e rForming losfallafion� � Phwie No. � �
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E&00001 A-11 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YFI.LOW COPY