P - 83943, REQUEST FOR ELECTRICAL INSPECTION
`� �(j � g 15 Minnesota State Board of Electricity
�� 1821 University Ave., Rm. S-128, St. Paul, MN 55104 �.
Phone(612)642-0800
Home
Commerc
Farm
New
Remod
Addn
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other.
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by ihis request. Enter remarks in this space and on the back of the white copy only.
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Calculate Inspection Fee - lhis Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance 'ze Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 00 Amps '� 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY OTAL �
�ign/Outline Ltg. Xfmr. �,,. �
Alarm/Remote Control
Swimming Pool
I hereb certi thaf I ins ed the electrical insfallation described herein on the dates stated
Irri ation Boom
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Investigative Fee `.--_.�. 7�
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TIi1S INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 monfhs from validation date prinfed in fhis box.
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Re uest Date Rou h-in ins ecfion re uired? pec g y ❑ Will Call
g p q ❑ Yes No Ins tion Other Tnan Rou h-In: ead Now
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I, � licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Street, ��r Route No.� City Zip Code
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Section No. Township Name or No. • Range No. Fire No. County .
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Occupanf Phone No.
('1 A� S 7i N 57/—S a 1►�A�ww� tc� �`� /- o
Power Supplier Adciress
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Elechicql Confr ctor (Company Name) Conhacfor License No. Master Lic. No. (Planf Elect. Only�
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(Contractor
ractqL or
Insfallofion)
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Phone No.
562 j ��z-�BS=�