P - 8153473b-527
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �;
Phone (612) 642-0800
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re air
Air Cond. Hig. 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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Calculate Inspection Fee - This Inspeciion Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders
Mobile Home Park Stall 0 to 200 Amps ✓ 0 to 100 Amps
Sfreet Ltg./Traffic Sig. Above 200 Am s Above 100 Ai
Transformer/Generator INSPECTOR°S USE ONLY T�,
Sign/Outline Ltg. Xfmr. j
Alarm/Remote Confrol
Swimmina Pool
Fee
S�
' 1 hereb certi tfiaf I ins fed fhe elechical installafion dexribed herein on the dates stafed
Irrigafion Boom Rough-In Date
Special Inspec
Final Date -
Investigative Fee �� •--
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This requesf void 18 months from validafion date prinfed in this box.
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PLEASE PRINT OR TYPE
Requesf te Rou h-in ins ection re uired?
g p q ❑ Yes o Inspection Other Than Rough-In: eady Now ❑ Will Call
(You musf call fhe inspector when ready� Date Ready:
I, censed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address �Sheef, Box, or Roufe No.) Cify Zip Code
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Secfion No. Township Nome or o.
Occu����� e
Power Supplier
Elecfrical nh or (Com y Name�
Mailing Address (C� or or Owner
Range No. �Fire No.
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Phone No.
!7�"p�.� � y3�
lo. � Masfer Lic. No. �Planf Elect. Only)
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1 A-11 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPv