P - 81478IIIU}tIIIIIIIIIIIIIII IIIIIIIIIIIIIIIIIIIIIIIIIIII R8 Q UEiSe sFORve.LRm. SR1C8 StN SPEnCNION04 �����
Minnesota State Board of Electncity �
* 0 3 8 9 6 7 9 2* Phone (612) 642-0800 ����
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Repair
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat emp. Service
"X" abov the work covered by this request. Enter remarks in this space and on the back of the w ite c y only.
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Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee � Service Entrance ' e 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 TOTAL ��
Sign/Outline Ltg. Xfmr. 2��'
Alarm/Remote Control
Swimming Pool I hereby certify that I inspected the electrical installation described herein on the dates stated
Irrigation Boom Rough-In Date
Special Inspe � � - � --
Final D�e ' �
Investigative F J
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.
389-679 �2 ,.,, ��, �
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PLEASE PRINT OR TYPE
Request Date Rough-in inspection required? •❑ Yes o Inspection Other Than Rough-In:� Ready Now ❑ Will Call
r��.� (You must call the inspector when ready) Date Ready:
I,� licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Jo ddress (Street, Box, or Route No.) City Zip Code
/� � .
Section No. Township Name or No. Range No. Fire No. C ty
Occupa Phone No.
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Power Supplier Address
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Electrical Contractor (Company Name) Contractor License No. Master Lic. No. (Plant Elect. Only)
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Mailing Address (Contractor or Owner Performing Install on)
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Author' Signature (Co ractor or Owner Performing Installation) Phone No.
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EB-00001A-11 8/95 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY