P - 80819' REQUEST FOR ELECTRICAL INSPECTION
c O�� Q 0 2 Minnesota State Board of Electricity
U O 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 e air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"" above the work covered by this request. Enter remarks in this space and on the back of ihe white copy only.
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Calculate Inspection Fee - 7his Inspection Request will not be accepted without the correct 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 ONLY T�L
Sign/Oudine Ltg. Xfmr. 4� 3��
Alarm/Remote Conhol
Swimming Pool
I hereb certi thaf I ins the elechical inslallafion described herein on �e dafes sfared
Irrigation Boo RougMn Dare
Special Ins
Finol D
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED !F NOT COMPLETED WITHIM 18 MON HS.
OFFICE USE ONLY This requesf void 18 months from validation dafe printed in ihis box.
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PLEASE PRINT OR TYPE
Requesf Dafe Rough+n inspecfion required8 ❑ Yes o Inspecfion Other Than Rough-In: ❑ Ready Now�i Call
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i" � (You musf call fhe inspedor when ready) Date Ready:
I, icensed contractor ❑ owner hereby request inspection of ifie above elecfrical work at:
Job Ad ress (Street, Box, or Ro�te No.� Ciy Zip Code
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Secfion No. Township Nome or . Range No. Fire No. ty
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Occupanf // Phone No. ,�.�� _ �
,� .A��LS' D�_',o .F/.',l,'s %./7� ��.��s�
Elechic Conhacror (Company Name) Conhacror License No. Master Lic. No. �Plant Elect. Or
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Mailing Address (Conha r or er Performirg Inslallation�
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Authoriz Sign e Conhacbr or Owner Perfor ' Installation Phone No.
. � ��30 -�� �
E&00001 A-11 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY