P - 8277966� 602 �
Home Duplex
Commercial Industr
Air Co . Htg. E�
Dryer Range
"X" above the work coverea
RE(1UEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
Apt. Bidg. Other: New Addn
Farm Remod Re air
Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
request. Enter remarks in this space and on the back of the white copy only.
Calculate Inspection Fee - This Inspection Request will not be accepted 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
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Oudine Ltg. Xfmr.
Alarm/Remote Conhol
Swimming Pool
1 here ceAi that I ins the elechical installafion described hcvein on the dates slated
Irrigation Boom RougMn Daie
Special Inspectio
Investigative Fee F�� � C�f � � O
THIS INSTALLATION MAY BE ORDERED_DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf wid 18 months 6om validation date prinfed in fhis box. ._
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* 0 6 6 9 6 0 2 5* ��6.3
PLEASE PRINT OR TYPE
Request Date Rough-in inspection required$ ❑ Yes o Inspecfion O�er Than Rougfrin: eady Now ❑ Will Call
� p�� .�� (You must call the inspec�or when ready� Date Ready:
I, icensed contractor ❑ owner hereby request inspection of the above elecfrical work at:
Job Addres�heet, x, or Ro �� � Ci1y � � Zip CodeA '
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Secfion No. T nship me or o. Range No. Fire No. County
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Occupant � 1 � Phone N . / �� , , —
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Power up iey� �j ddress � j� �
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EI 'cal Contractor (Com ny Name Conhacfor License No. Master Lic. No. (Planf Elecf. Only)
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Mai Address (Conhacror or r Perfo 'ng Installation) � � �� //��� _ a�
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Au ori Sig alure Conhacfo or Ow erforming Installafioo � (;� � Phone N�� ��
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E A-11 8/96 ST BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY