P - 80141REQUEST FOR ELECTRICAL INSPECTION
�(�� � v`� �� � Minnesota State Board of Electricity
v `� 1821 University Ave., Rm. S-128, St. Paul, MN 55104 =
Phone(612) 642-0800
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm J� �/'y! �✓' !� Remod Re air
Air Cond. Hfg. Equip. Water Htr. Load Mgmt. Other. 5e��2✓/ c�
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space�nd on t e back of the white copy only.
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Calculate Inspection Fee - This Inspection Reqvest will not be accepted wi►hout the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator I PECTOR'S USE ONLY TOTAL
Sign/Outline Ltg. Xfmr. �9 � �
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ihe electrical installation described herein on the dates slated
Irrigation Boom RougMn p�e
Special Inspection �
Final Da
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void l�months (rom validafion dafe prinfed in this box.
I���I II �II II I�I I) III II II) II III II �I ���� I� 3� ,�-� 5�0 /
* 0 8 0 2 3 5 3 3* �`�
PLEASE PRINT OR TYPE
Request Dafe Rough-in inspecfion required$ ❑ Yes Inspecfion Ofher Than Roughan: Now ❑ Will Coll
�� ���(� ��� (You musf call the inspector when ready) Date Ready:
I, �licensed conhactor ❑ owner hereby request inspection of the above elecfrical work at:
Job Address (Shcet, Box, or Route No.) Ciy Zip Code
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Secfion No. T ship Name or No. Ranpe No. Fire No. ounty
Occupant �i (� ('�
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Power Supplier /�
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Elechical Confrac�or �Company Name)
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Mailing Addre�acior�Own�rfoCr ng InsMl
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Aufhorized Signature� r or ner P m�l
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STATE BOAR�j
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Phone No.
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Conhactor License No. Masler Lic. No.
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�tion) Phone No.
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- SEE INSTRUCTIONS ON BACK OF YELLOW COPY
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