P - 82387RE(�UEST FOFi ELECTRICAL INSPECTION �
Q� Z���� � Minnesota State Board of Electricity �%
� 1821 University Ave., Rm. S-128, St. Paul, MN 55104
` Phone(612)642- 800
Home Duplex Apt. Bldg. Otheri �V New Addn
Commercial Industrial Farm /� Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Drye Range Elec. Heat Temp. Service
"X" above the work covered by this relquest. Enter remarks in this space and on the back of the white copy only.
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Calculate Inspection Fee - This Igspection Request will rot be accepied without fhe correct fee:
Other Fee # Serv' ntrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 t 20 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY T TA
Sign/Outline Ltg. Xfmr. ��J �
Alarm/Remote Control
Swimming Pool i hereb certi that I ins the elechical installafion dexribed herein on the dales sfaled
Irrigation Boom RoogM� ��y, f,��SQ
Special Insp 'o �� V
F,na� � /�Z
Investigative c
THIS INSTALLATION MAY BE ORDERED DISCONNE D IF NOT COMPLETED WITHIN 18 MONTHS.
� - OFFICE USE ONLY This requeaf void 18 months from validation date printed in this box.
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PLEASE PRINT OR TYPE
Requesf Date Rough-in inspection required$ �Yes ❑ No Inspecfion Other Than RougFFln: ❑ Ready Now Will Call
q��` Qv (You must call the inspector when ready) Date Ready:
I, �icensed conhacror ❑ owner hereby request inspection of the above electrico) work at:
Job Address �Street, Box, w Route No.) Ciy � Zip����
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Secfion No. Township Name w o. Range No. Fire No. County J,/�J
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Occupo Phone No.
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Power Supplier Addre
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Electrical Conhactor (Company Name) Contractor license No. Masfer Lic. No. (Pbnl Elecl. Only�
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Mailing Address �Contractor w Owner PerForming InsMllation)
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Aufhorized Si re �Conkactor or er P rForming InstallaKon) Phone No.
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E���'41 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY