P - 81465RE(IUEST FOR ELECTRICAL INSPECTION --�
5 3�= 3 4 4 Minnesota State Board of Electricity
� 1521 University Ave., Rm. S-128, St. Paul, MN 55104
, Phone(612)642-0800
ome Duplex Apt. Bldg. Other: New Addn
� Commercial Indushial Farm emod Re ir
Air Cond. Hfg. Equip. Woter Hfr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on Fhe back of the white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted withovt fhe correct fee:
Other Fee # Servi e Entrance ' e Fee # Circuits/Feed�
Mobile Home Park Stall 0 to 00 Amps Z, 7 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100
Transformer/Generator INSPECTOR'S USE ONLY T['
Sign/Oudine Ltg. Xfmr.
Alarm/Remote Confrol
Swimming Pool
Irriqation Boom
Fee
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that I inspected the eleclrical insfallafion described herein on fhe dafes stated
�re
�nvcm�yunvC Pee `� � - —� —
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONT S.
OFFICE USE ONIY This request wid 18 months from validation date printed in this box.
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PL SE PRINT OR TYPE
Requesf Dafe Rough-in inspecfion required? ❑ Yes o Inspecfion OTher Than Rough-In: ❑ Ready Now ill Call
S�You musf call the inspecfor when ready) Date Ready:
I, icensed conhactor ❑ owner hereby request inspection of the above elechical work at:
Job Address (Sheet, Box, or Roufe No.) Ciy � Zip Code
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Seclion No. Township Name or No. Range No. Fire No. CounNi
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Company Name)
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�h r or Owner Performing Installafion)
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(Confracfor or Owner Pg�orming InstalJp
Phone No.
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r License No. Maste
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tUCT10NS ON BACK OF Y
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Phone No.
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