P - 84254-�33�4_�3 �
RE(�UEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
�( Home Duplex Apt. Bldg. Uther:
Commercial Industrial Farm
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
New
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the white copy
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Calculate Inspection Fee - This Inspection Request will not be accepted without the 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./Trar`fic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL�
Sign/Outline Ltg. Xfmc '
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ted the elechical installation described herein on the dates stated
Irrigation Boom „� Rough-In ���� .� G%Y
Special Inspecti f � �
Final Date
Imestigative Fee _ —
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NaT COMPLETED WITHIN 18 NiONTHS.
OFFICE USE ONLY This request void 1 S months from validation dafe printed in fhis box.
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Request Date Rough-in inspection required? Yes ❑ No Inspection Olher Than Rough-In: ❑ Ready Now � Will Call
1� /� ��r (You musi call the inspector when ready) Date Ready:
I, �licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Street, Box, or Route No.� City Zip Code
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Section No. Township Name or No. Range No. Fire No. County
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Elecfrical Conhactor (Company Name)
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Mailing Address (Conhacfor or Owner Performing Insfallafion)
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Authorized Signature �Conhacror or Owner Performing Installc
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8-00001 A-11 8/96 STA BOARD COPY
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Conhactor License No. fv
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�IONS ON BACK OF YELLOW COPY
Lic. No. (Plant
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