P - 80691i � REQUEST FOR ELECTRICAL INSPECTION �
7 V �-� 3 4 Minnesota State Board of Electricity
, 1821 University Ave., Rm. S-128, St. Paul, MN 55104 �:
Phone(612)642-0800
ome Duolex Aot. Blda. Other: New Addn
Commercial Industrial Farm Remod ;
Air Cond. . quip. 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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Calculaie Inspection Fee - This Inspection Request will no► 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
Sfreet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL,�
Sign/Outline Ltg. Xfmr. � •
Alarm/Remote Confrol �_� �
Swimming Pool
I hereb certi that I ins ted the elechicai instaltation described herein on the dates staMed
Irri9atiOn Boom RougMn Date
Irnestigative Fee ` � "�" `''v�-'�'�
IS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 monfhs kom validafion date printed in this box.
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PLEASE PRINT OR TYPE
Requ f Date Rough-in inspecfion required2 ❑ Yes o Inspecfion Ofher Than Rough-In: eady Now ❑ Will Call
��.� (You musf call the inspecfor when ready) Date Ready:
I, licensed conhactor ❑ owner hereby request inspection of the above electrical work at:
1ob Addreu (Sheet, Box, or Route No.) Cily Zip Code
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Seclion No. Township Name or No. Ranpe No. Fire No. Cou
Occ��-�" ""'�
Power Supplier
EI ic I Contractor (Company Name)
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Mailing Address (Conkactor or Owner Perl
License
Phone No.
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ignature (Conhacror or Owner Perfurmi In Phone N.
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1 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF COPY