P - 84767REQUEST FOR ELECTRICAL INSPECTION - :�
'��r�� 3� 1� 4 Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
Home Duplex Apt. Bldg. Other: New Addn
Commercial Indusfrial Farm Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. pther:
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.
Calculate Inspection Fee - This Inspection Request will not be accepted without ihe correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Siq. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Outline Ltg. Xfmr. p:lk" 2'�=''r /,j� ��
Alarm/Remote Control
Swimming Pool
I hereb certi thaf I ins fhe elechical insfallafion described herein on the dafes stafed
Irrigation Boom RougMn Dare
Special Insp . ' �
Investigative Fee �l
THIS INSTALLATION MAY BE ORDERED DISC TED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 monfhs from validation date printed in fhis box.
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Request Date Rough-in inspection required2 ❑ Yes ❑ No Inspecfion Ofher Than Roughdn: ❑ Ready Now ❑ Will Call
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I, �ficensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sfreef, Box, or Roufe No.) City Zip Code
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Secfion No. Township Name or No. Range No. fire No. County
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Occupant Phone No.
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Power Supplier Addres '
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Elechical Conhactor (Company Name) ContraNOr License No. Masfer Lic. No. �Plant Elect. Only)
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Mailing Address (Conhacfor or PerForming Insfallation�
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Aufhorized Signafure �Conhacfor or Owner Pe rming Insfallation� ��� 1� .' Phone No.
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Ol A-11 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY