P - 83226RE(�UEST FOR ELECTRICAL INSPECTION
�/� � o p� Q � Minnesota State Board of Electrisi#y �
y� ,,D O 1821 University Ave., Rm. S-128, St. Paul, MN 55104
� ' Phone (612) 642-0800 `'�°'
ome Duplex Apt. Bldq. Other: New Addn
Commercial Industrial Farm Remod
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 space and on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Requesf will no; be accepted without the correct fee:
Other Fee # Servi ntrance 'ze Fee # Circuits/Feeders Fee
Mobile Home Park Stall t 20 Amps ' 0 to 100 Amps
Sfreet Ltg./TrafFic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL �-p
Sign/Outline Ltg. Xfmr. S �'�
Alarm/Remote Conhol
Swimminq Pool . . _ . _ . . . . _ .. _ . . .. . . .
$pecial Inspeb�vo4) ry F.�
Investigative Fee ,/�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED FF NOT COMPLETED WI IN 18 ONTHS.
OFFICE USE ONLY This request void 18 months 6om validation dafe prinfed in this box.
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PLEASE PRINT OR TYPE
Request Date �j Rough-in inspeclion required$ ❑ Yes o Inspecfion Other Than RougMn' Now ❑ Will Call
�'/� �" p O (You must call the inspeclor when ready) Dofe Ready:6 :�
I, icensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address �Street, Box, or Route No.) Ciy Zi Code
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Section No. Township Name or No. Range No, Fire No. Counly
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Occu nt Phone No.
ede`t, �o/Qc�t�i ��y- S7[3
��rre � /� naoress
S r
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Elec ical Co fracfor (Company Name) Conhacfor License No. Masfer Lic. No. (Plant Elecf. Only)
s% �'�/lic nG ov � 2
Mailing Address � ontractor or Owner Performing Installation�
o� CehT�a l v � � �; �� �k�e ��' ,�'5�..3�
Author' ture �Conhactor or Owner PerForming Ins Ilaf' pho�e No i
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E&00 8 6 STATE BOARD CO - INSTRUCTIONS ON BACK OF YELLOW COPY