P - 841904�3�-090 ._�
REQUES'F FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800
Home uplex Apt. Bldg. Other:
Commercial Industrial Farm
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this spcce and on the back of the
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Calculate Inspection Fee - This Inspection Request will not be accepted without ihe correct fee:
Other Fee # Service Entrance Size Fee # Circuits
Mobile Home Park Stall 0 to 00 Amps 0 to 100 A
Street Ltg./Traffic Sig. Above 200 Amps Above 100.
Transformer/Generator INSPECTOR�s usE oN�v
Sign/Outiine Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
New
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copy only.
Fee
SQ
I hereb certi fhat I ins cted }he electrical installafion described herein on the dafes stated
Irri9ation Boom Rough-In Da
Special Inspe " - "Z-1�
Investigative Fee � •�' F���I c� —
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 1 8 months from validation date printed in fhis box.
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* � 4 2 3 � 9 0 �* PLEASE PRINT OR TYPE
Requesf Date Rou h-in ins tion re uired?
g pec q ❑ Yes Inspxtion Other Than Rough-In: Ready Now �Will Call
f"'�G�% ��,.��j �You must call fhe inspector when ready) Dafe Ready:
I, � licensed contractor ❑ owner hereby request inspection of the above electricaf work at:
Job Address �Street, Box, or Route No.� � Ci .. " Zip Code
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Section No. Township Name or No. Range No. Fire No. County/} /
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Occupa%� /, / / Phone No. /
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Power Supplier q$ ,� Addre� � : . '
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Elechical Conhactor (Company Name) Confracfor License No. Master Lic. No. (Plant Elecf. Only)
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Mailin Address (Conhacfor or Owner Performing Installation /�
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INSTRUCTIONS ON BACK OF YELLOW COPY