P - 82167U����87-955 �
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Avenue Sui[e 5-128, Saint Paul, Minnesota 55104-2993
(651) 642-0800 www.elecfricity.sfate.mn.us
Duplex Apt.8ldg. Other:
Indusfrial Farm
Hfg, Equip. Water Htr. Load Mgmt
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Addn
Repair
"X" above the work covered by this request, Enter remarks in this space and on the back of the white copy only.
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Calcvlate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Installations Fee #$ervice Enfrance Size Fee # Circuits / Feeders Fee
Mobile Home Park Stall
$treet Ltg. / TrafFic Sig.
Tra nsformer/Generator
$ign / Outline Ltg. Xfmr.
Alarm/Remote Control
Swimminp Pool
0 to 200 Amps
Above 200 Amps
INSPECTOR'S USE ONLY
fhat I inspecfed the elechical installafion
0 to 100 Amps
Above 100 Amp:
TOTAL
Date
S�O
Investigative Fee rinai � � v„�' I ��--,� � a��l
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THtS INSTAILATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 months from validation date prinfed in fhis box.
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PLEASE PRINT OR TYPE
Request Date�/� Rough-in inspecfion required$ ❑ Yes �lo Inspection Ofher Than Rough-In: ❑ Ready Now ill Call
�� 15 ^' Q%(�OC7 You must ca�l the inspector when reody Dafe Ready:
1, licensed controctor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address �Streef, Box, or Rou e No.) City Zip Code
75/ 9'� Q�--- N� �"�e r ��� s's'y.��z
Section No. Township Name or No. Range No. Fire No. County
Occupanf
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Power Supplier Address
Elactrical Contracfor / Compony
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Mailin Address (Contmcror, Compqny or Owne Performing I"nsta�ll ti�
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Authorize ignature (Contractor, Co any or er Pe�
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EB- 0001A-12 5/1999 RTATF AnABD CAPY
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Phone No.
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No. Master Lic. No. (Plant Elecl. Only
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SFE INSTRl1CT1�NS �N HACK �F VELLOW COPY