P - 83031REGIUEST FOR ELECTRICAL INSPECTION
E�����O � Minnesota State Board of Electricity
J 1821 University Ave., Rm. S-128, St. Paul, MN`55104�
Phone (612) 642-0800
Home Duplex Apt. Bldg. Other: New ddn
Commercial Industrial Farm Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Efec. 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 Request will not 6e accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to lOQ Amps 3p, DE
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY AL
Sign/Outline Ltg. Xfmr. 3�"sb
Alarm/Remote Control �
Swimming Pool
I hereb certi fhaf I ins fhe elechica ' sfallafion described herein on the dafes sfated
Irri9ation Boom RougMn D�e y�/
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1"nvestigative Fee` '" " —�� G
THIS INSTALLATION MAY BE ORDERED DISCONNE TED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request wid 18 months from validation date prinTed in fhis box.
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PLEASE PRINT OR TYPE
Request Dafe Rough-in inspection required8 es ❑ No Inspection Other Than RougMn: ❑ Ready Now i I Call
�� / g.. 9� (You musf call the inspecfor when ready) Date Ready:
I, �ensed conhactor ❑ owner hereby request inspection of the above electrical work ai:
lob Addreu �Street, Box, or Route No.) Ciy � Zip Code
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Section No. Township Name or No. Range No. Fire No. C ur�ty
Occupant
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Power Supplier A�
Eleclricnl Conhactor �Company Name)
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l�v ailing Address (Conhacfor or Owner Pe orming Installation�
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utho re (Contractor or ner Performing I stallaf
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i&OOOOIA-I 1 96 STATE BOARD COPV -
Conhactor License
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Phone No.
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lic.
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ON BACK OF YELLOW COPY