P - 84640. ��d,o� o �i� _
/� /� REf�UEST FOR ELECTRICAL INSPECTION
�i�� �-F — 411 Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paui, MN 55104
, Phone(612)fi42-0800
Home Duplex Apt. Bldg. Other: New Addn
Commercial Indusfrial Farm Remod Re ir
Air Cond. Htg. Equip. Water Hh. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above ihe work covered by this request. Enter remarks in this space and on the back of ►he white copy only.
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Calculaie Inspection Fee - This Inspection Request will not be accepted without the correci fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Sheet Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOT�AL�
Sign/Outline Ltg. Xfmr. �j t �
Alarm/Remote Confrol
Swimming Pool
I hereb certi thaf I ins ed the elecfrical installaKon described herein on the dates stated
Irrigation Boom Ro�Mn pa�
Special Inspect'
Investigative F F� -' �O� D .•-
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THIS tNSTALLATION MAY BE ORDERED DISC TED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 monfhs from validafion date prinfed in fhis box.
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PLEASE PRINT OR nPE
Request Date Rough-in inspecfion required2 ❑ Yes No Inspection Other Than RougMn: QlReady Now ❑ Will Call
� Q� � (You musf call the inspecfor when ready) Date Ready: � 6�
I, �licensed contractor ❑ owner hereby request inspection of the above elecfrical work at:
Job Address �Sheet, Box, or Route No.) City Zip Code
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Section No. Township Name w No. Range No. Fire No. Co ty_
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Power $upp�ier
Conhacfor (Company Name�
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lddress (Conhacfor or Owner Performing Inslallafion)
'q� w _ �g'�' Sfi
d Signature (Conhaclor or Owner Performing Installa
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Phone No.
S��- �s'�s"
Conhaclor License No.
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Master
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY