P - 84656� RE(IUEST FOR ELECTRICAL INSPECTION
�F � O— 4 4 4 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 Indushial Farm Remod Re ir
Air Co Htg. Equip. Water Hfr. Load Mgmt. Other:
ryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the while copy only.
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Calculate Inspection Fee - This Inspection Reques► 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 TOTA�� SO
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
I hereb certi that 1 ins ted the electrical installation described herein on the dates stated
Irrigation Boom RougMn Date
Special Inspec '
final Do�
Investigative F � ' l �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 ONTHS.
OFFICE USE ONLY This rec{uesf void 18 months from validafion dafe printed in fhis box.
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* � 4 7 8 4 4 4 3�K PLEASE PRINT OR TYPE
Request Dafe Rough-in inspection required? ❑ Yes No Inspection Other Than Rough-In: Ready Now ❑ Will Call
� 7 (You must call the inspecfor when ready) Date Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
1ob Address (Sheet, Box, w Roufe No.) City Zip Code
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Secfion No. Township Name r o. Range No. Fire No. C nly
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Occupa t Phone No.
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Power Supplier Address
Elechical Conhactor (Company Name) Conhactor License No. Master Lic. No. �Plont Elecf. Only)
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Mailing Addr s �Conhactor or Owner PerForming Ins/allafion) ! � f � I�
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Aufhorized Signafure (Conhact or Owner Performing Insta o Phone No.
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