P - 80324REQUEST FOR ELECTRICAL 4NSPECTION ��9
lJ �`� �� f` 5 6 4 0 Minnesota State Board of Electricity 3
4 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993
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�� (651) 642-0800 www.eleCtricity.state.mn.us ''�'
Home Duplex Apt. Bldg. Other: New Addn
Commercial Indusirial Farm emod Repair_
Air Conditioner 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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Calculafe Inspec►ion Fee - This Inspection Request will not be accepted without the correct fee:
Other Insta4lations Fee # Service Entrance Size Fee # Circuits / Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg. / Tra{fic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTA� ��
Sign / Outline Ltg. Xfmr. d
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ected the eleckical installation described herein on the dates stated:
Irrigation Bo RougMn Dafe
Speciallnsp o
Final D e
Investigative Fee �"�'�-'�—� �
THIS 1NSTALLATION MAY BE ORDERED DISC NECTED IP NOT COMPLETED WIT N 18 ONTHS.
OFFlCE USE ONLY This requesf void 18 monlhs 6an validation date printed in fhis box.
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PLEASE PRINT OR TYPE
Request Date Rough-in inspection required$ ❑ Yes No Inspecfion Other Than Rough-In: ❑ Ready Now �/ill Call
� ,_ 0�� You must call fhe inspecfor when ready Dafe Ready: �.
1, �licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
- Job Address (Streef, Box, or Roufe No.) - City �� . Zip Code
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Section No. Township Name or No. Range No. Fire No. County '
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Occupant Phone No.
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Power Supplier Address .
Electrical Conhacfor / Company Name Conhactor License No. Master Lic. No. (Planf EIeM. Only�
BU�E tA,�A�O i��vc. C�90 i � qle
Authorized S' ture� (Con cto , pany or Owne I on) Phone Numbar
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EB-00001A-1 5/1999 STOrF wnnwn rnav CFF INSTGIICTIf1NS f1N RACK OF VFI 1 f1W C(1DV