P - 81508� REQUEST FOR ELECTRICAL INSPECTION
7��� n� O Minnesota State Board of Electricity
; 3 1821 University Ave., Rm. S-128, St. Paul, MN 55104 �
Phone (612) 642-0800
Home Duplex Apt. Bldg. Other: w Addn
� ommercial Industrial Form emod Re air
Air Cond. Htg. Equip. Water Hir. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Se ice
"X" above the work covered by this request. Enter remarks i 's spa and back of the whife copy only.
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�culate Ins ection Fee - This Ins eciion Re uest will not be cce ted without the correct fee:
P P 9 P
Other Fee # Service Entrance ize F # Circuits/Feeders Fe (
Mobile Home Park Stall 0 to 0 Amps 0 to 100 Amps
Street Lfg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR�S use oN�v TOTAL� �
Sign/Outline Ltg. Xfmr. 'N
Alarm/Remote Control
Swimming Pool
I hereb ceAi fhat I ins ted fhe elechical insfallafion dexribed herein on the dates stated
Irrigation Boom Roo9l�lo pare
$pecial Inspectio
Fina)
Investigative Fee � � D�� Z " ^
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 monfhs from validafion dafe prinfed in this box.
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PLEASE PRINT OR TYPE
R u t Dafe Rough-in inspecfion required? ❑ Yes No Inspeclion Olher Than Rough-In: ❑ Ready Now ill Call
✓ �� 9 (You musf call fhe inspecfor when read Date Ready:
I�i¢ensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Addr $heef, Box, oL oufe�lE� A_ /� ^�l Cf�y � J Zip Code
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Secfion No. Township Name or No. Range No. Fire No. Couny A�Q ,, ^
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P ' O +ijJ T / • ' 1'i �V V � '! ��/ � Phone No. � �JD�
Power Supplier Address � � `
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EI ' I Conhacto� om ny Name� ^� Conh or li ense No. Masfer Lit. No. (Planf Elecf. Only)
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Maili g Addre nhactor or ner Performing Ins� ��� , ^` � ��� �
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Authorized a �Con ctor or Owner Performing Installafion, 2 6 9�� Phone No.
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EB-0 1 A- 9 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF ve��ow coav