P - 83048REQUEST FOR ELECTRICAL INSPECTION
` Q Minnesota State Board of Electricity
6 8 5� � V o 1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
Home Duplex Apt. Bldg. Other: �� ,n �/',U New
Commercial Industrial Farm �� ���� Remoc
ir �Af� Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered b this request. Enter remarks in this space and o the back of the white copy
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Calculate Inspecfion Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feedi
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100
Transformer/Generator INSPECTOR'S USE ONLY TC
Sign/Oudine Ltg. Xfmr.
Alarm/Remote Confrol
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Fee
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I hereb certi that I ins ected the electrical instollation described herein on the dates stated
Irrigation Boo Rough-In Date
Special insp f
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Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 from validation dafe printed in fhis box.
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PLEASE PRINT OR TYPE
Request DQte O Rou h-in ins ction r uired?
�, 9 pe eq ❑ Yes InspecFion Other Than Rough-In: eady Now ❑ Will Call
��• �v (You m�st call the inspecfor when ready) � Dute Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
lob Address (SReet, Box or Route ! City Zip Code
Seclio ownship Name or No. ange No. � Fire No. County n � ��
Occupanf
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Power Su plier � Addres:
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Mailing Address �Contracfor or Owner Performin Insfallafion�
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Confracfor License � o. �., `
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- SEE INSTRUCTIONS ON BACK OF YELLOW COPY
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Lic. No.