P - 84163REQUEST FOR ELECTRICAL INSPECTION -
5�C ��, � 7� Minnesota State Board of Electricity
� � 1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800 '�'
Home Duplex Apt. Bldg. Other. � New Addn
Commercial Industrial Farm �-C"-�- ���� emod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other: r� �
Dryer Range Elec. Heat Temp. $ervice ��-i..l r'\.1 ��"
"X" above the work covered by this request Enter remarks in this space and on the b ck of the white copy only. r�
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Calculate Inspection Fee - This Inspection Request will not be accepted without th�rect��v�J " �
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY T�TA�
Sign/Outline Ltg. Xfmr. f�
Alarm/Remote Control � a
Swimming Pool
. I hereb certi thaf I ins ted the electrical installation described herein on the dates siated
Irrigation Boom Roo9h-i� Date / q
Special Inspect' �"—` �l`
Final Da�a. �
Investigative Fe „�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validation date printed in this box.
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* � 5�a 7 2 7 2 O* PLEASE PRINT OR TYPE
Requesf Dafe Rou h-in ins tion r uired2 Yes
g pec eq ❑ No Inspection Ofher Than Rough-In: ❑ Ready Now Will Call
�You musf call fhe inspecfor en readyJ Dafe Ready:
I, icensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address �Street,,Box, or Route No.� � City /f Zip Code -
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Section No. Township Name or No. Range No. Fire No. Cou
Occupanf
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Power Supplier Address
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Elecfrical Conimctor (Company Name�
Mailing Address ontractor or Owner Performing lation)
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� Aufhorized Signature C o or Owner Performin Ins lafi �
EB-OOOOlA-1 1 6 ATE BOARD COPY - SEE I
Phone No.
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Phone No.
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