P - 83149REGIUEST FOR ELECTRICAL INSPECTION
����''i`� /I Q� Minnesota State Board of Electricity
�L �'f �� �a 1821 University Ave., Rm. S-128, St. Paul, MN 55104
` Phone (612) 642-0800 �
Home Duplex Apt. Bldg. Other. / �` ��� New
Commercial Industrial Farm � � Remoc
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work ov red b this request. Ent remarks i t is space and on.the back f the white c y
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Calculate Inspection Fee - This Inspection Request will noi be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders
Mobile Home Park $tall 0 to 00 Amps ` a`�5�� 0 to 100 Amps
Sheet Ltg./Traffic Sig. ,46ove 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY T'
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Fee
Sign/Oudine Lig. Xfmr. � � (1 /( � V
Alarm/Remote Control ° � �*
Swimming Pool
I hereb certi that I ins the eleclrical inslallafion described herein on the dates stated
Irrigafion Boom Rouglrin „ �
Speci6 n pection
Final �
Investigative Fee � l �
TH1S INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFRCE USE ONLY Thia roquesf wid 18 months kom wlidafion date prinfed in this box.
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* � 5 3 2 4 9 3 �F * PLEASE PRINT OR TYPE
Request Da�e Rou h-in ins ion r uired$ � Yes
g pecf eq ❑ No Inspection O�er Than RougMn: ❑ Ready Now Will Call
� (� g (You must call the inspec�or when ready) Date Ready:
I, ❑ licensed contractor � owner hereby request inspection of the above electrical work at:
Job Address �Sheet, Box, or Route No.) City Zip Ca
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Seclion No. Township Name or No. Range No. Fire No. Couny
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OccupaM Plwne No.
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Mailing Address (Conhactor w
No. i n�5r�. u�. r�.
Owner Performing Installafion) I ph��� �
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ATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY
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