P - 81658RE(�UEST FOR ELECTRICAL INSPECTION
6 6 2 ��� � Minnesota State Board of Electriciry
1821 University Ave., Rm. S-128, St. Paul, MN 55104
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� Phone(612)642-0800
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above ihe work covered by this request. Enter remarks in this space and on the back of the white copy only.
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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 Oa$�d
Sireet Ltg./TraFFic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY T �.r
Sign/Outline Ltg. Xfmr. �v a
Alarm/Remote Conhol
Swimming Pool I hereb ceni that I ins ected the elechical installation described herein on fhe dares sfared
Irrigation Boom RougMn ��
Speciallnsp 'on
Final
Imestigative - � Z —0
THIS INSTALLATION MAY BE ORDERED DISCONN CTED IF NOT COMPLETED WITHIN 18 MONTHS.
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OFFICE USE ONLY This roquesf wid 18 months from validafion dafe printed in this box.
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PLE SE PRINT OR TYPE
R�esf fe � Rough-in inspecfion required? ❑ Yes o Inspecfion O�er Than RougMn: ❑ Ready N ill Call
�` � �� (You must call the inspeclor when ready) Date Reody:
I, licensed confractor ❑ owner hereby request inspection of the above electrical work at:
Job dress (Sheet, Box, or Route No.) Ci ZiP C°de
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Secfion No. Township Nome or No. Range No. Fire No. Cou
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Occupant � Phone No. �
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Power Supplier . Address �
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Elec ical ontracror (Company Name) _ Conhacror License No. Master lic. No. (Planf Elec1. Only)
Mailing Address (Conhacror or ner PerForming Installation)
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Authorized Si (Conkactor or ner PerFor m I�tallation) Phon No. �
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EB-0OOOlA-1 1 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY