P - 83167REf�UEST FOR ELECTRICAL INSPECTION ��-�
5� L- 4 9 5 Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
f Phone(612)642-0800
Home Duplex Apt. Bldg. Other: New ' Addn
Commercial Industrial Farm Rem Re air
Air Cond. Htg. Equip. Water Hfr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work cov ed by this request. Enter remarks in this space and on the back of Ihe whiie copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted without the corcect fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps � 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR�s use oN�v TOTALj
Sign/Outline Ltg. Xfmr. �� �j� � � n „ /,
Alarm/Remote Control � � j � �1 �>;
�.r� -:_:" ?' =
Swimming Pool
I her ceAi Ifw1 I ins the eleclri inslallalion described herein on the da�es slafed
Irrigation Boom eougMo �� p'
Speciol Inspection �
Final
Investigative Fee �
THIS INSTALLATION MAY BE ORDERED DISCON D IF NOT COMPLETED W IN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validaBon date printed in this box.
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* � J� 3 2 4 9 5 9* PLEASE PRINT OR TYPE /
Request Dafe Rou h-in ins �
g pection required? ❑ Yes ❑ No Inspecfion Olher Than RoughJn: ❑ Ready Now ❑�II Call
v �You must coll 1he inspecror when ready) � Da1e Ready:
I, ❑ licensed conhactor � owner hereby request inspection of the above electrical work ah
Job Address (Streef, Box, or RoNe No.) City � Z�P C� ..
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Section No. Towns ip Name or No. Range No. Fire No. Coun
Z / / I Phone No.
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tlechicol Contrac�or (Company Name) Co�L�n�� W1oxler lic. No.
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Mailing Address (Conhactor w Owner Performing Installa�on� E
Authorized Signahire (Conhacfor or Owrrer P rforming Ins/ollafion) p�� �.
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E&000p1A-11 8/96 �p ARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY