P - 83296REGIUEST FOR ELECTRICA�,�VSP�CTION `�
1 O 4-15 3� Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �.
Phone (612) 642-0800
Home Duplex Apt. Bldg. Ofher: 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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Colculaie lnspection Fee - Tbis Inspection Request will not be pccepied without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps p p 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL �r—
Sign/Outline Ltg. Xfmr. �J D
Alarm/Remote Control
Swimming Pool
I hereb certi thaf I ins cfed the elechical installafion described herein on fhe dafes sfated
Irrigation RougMn Dare
Speciallns '
Final Dot�dv
Investigative Fee C
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 months (rom validafion dafe prinfed in this box.
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PLEASE PRINT OR TYPE
Request Daf.e �_�� Rough-in inspecfion required$ ❑ Yes o Inspecfion Ofher Than Rough-In: eady Now � Will Call
(You must call the inspector when ready) Date Ready: �� ti�/�- 5"i �
I, icensed contractor ❑ owner hereby request inspection of the above electrica! work at:
lob Address (Street, Box, or Route No.) '�--� Zip Code
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Secfion No. Township Name or No. Range No. Fire No. County
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Occv nt Phone No.
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Power Supplier Address
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Ele rical Contractor (Company Name) Conhactor License No. Master Lic. No. (Planf Elect. Only)
S��e C�ec�r�Q � c�"a� c �!� oa/� �
Mailing Addr s(ConAacror or Owner Perform'ing Installationj
�2o�CepTRa� � � S�iT'�/� S �Q�n Lu.�'c /��tl� . Sf`1�3•`Z
Auth ized Si afure (Conhacfor or Owner Performing 1 tall ' n{� Phone No.
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EB-00001 1 8 9 STATE BOARD CO - E INSTRUCTIONS ON BACK OF YELLOW COPY