P - 83505"� REGIUEST FOR ELECTRICAL INSPECTION �
��� J- 5 7 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 Industrial 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 the back of the white copy only.
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Calculate Inspection Fee - This Inspection Requesi will not be accepted without the correct fee: I
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee '
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Lfg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Outline Ltg. Xfmr. �s''sv
Alarm/Remote Control
Swimming Pool
I hereb certi that 1 ins the electrical installafion described herein on the dates stated
Irrigation Boom Rough-In �"' �, �i ^C—i
Speciallnsp ' � � ~ l
Final � 1' jl
Investigative Fee - !�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months 6om validation date printed in fhis box.
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1 III) II III I) III (I III I II II III I) II) II III I IIII �
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* � 4 5 5 5 7 4 4* PLEASE PRINT OR TYPE
Request Date Rou h-in ins tion r uired2 �'¢s
g pec eq ❑ No Inspection Olher Than RougMn: ❑ Reody Now Will Call
7'u $ �You must call the inspector when ready) Date Ready:
I, �Jicensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sfreef, Box, or Route No.) City Zip Code
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Secfion No. Township Name or No. Range No. Fire No. ounty .
Occupanf
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Power Supplier Address
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Mailing Address (Contractor or Owoer PerForming Installation�
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Authorized�$iynature (Conhacfor or Owner Performing Installation)
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Phone No.
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Conhactor License No.
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iCT10NS ON BACK OF YELLOV
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one No.
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