P - 80636� REQUEST FOR ELECTRICAL INSPECTION
8 o G� � Q� O � Minnesota State Board of Electricity
V 1821 University Ave., Rm. S-128, St. Paul, MN 55104 -
`� Phone (612) 642-0800
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Home Duplex Apt. Bldg. Other: New Addn
Commercial Industria) Farm Remod Re air
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 ihe back of the whiie copy only.
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Calculate Inspection Fee - This Inspec on equest will not be accepted without the correc� fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
$treet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generafor INSPECTOR'S USE ONLY TOTAL
Sign/Outline Ltg. Xfmr. �•�
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ted the electrical installation described herein on the daTes smted '
Irrigation Boom RougMn Date
Special Insp
Finol Da
Investigative Fee Z�--O�
THIS INSTALLATION MAY BE ORDERED DIS ECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf wid 18 months (rom validation dafe prinfed in fhis box.
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* 0 8 0 5 8 6 0 4� ��(j�
PLEASE PRINT OR TYPE
Request Dafe Rough-in inspection required? ❑ Yes ❑ No Inspection Ofher Than RougMn: Ready Now ❑ Will Call .
� - �You must call fhe inspecfor when ready) Date Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Addreu (Skeet, Box, ou N.) City �_ Zip Code
J � •'
Seclion No. Township Name or No. Range No. Fire No. County
Occupant � " Phone No.
Power Supplier Address
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Elecfricol Conhacfor (Company Name) Confracfor License No. Masfer Lic. No. (Plant Elecl. Only)
DEPENDA�BLE r' nstollation� f° m�G `3
•on Rapids,�ig����
�71gp�
Authorized Signafure �Conhacfor ner Performing In fio hone No.
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EB-OOOOlA-11 8 6 �p7E OARD PY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY