P - 83889_a � REQUEST FOR ELECTRICAL INSPECTION �
5�� �— 5 5 7 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. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this reques�. Enter remarks in this space and on the back of the white copy only.
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Calculate Inspeciion Fee - This Inspection Reqvest will not be accepted withoui the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee !
Mobile Home Park Stall 0 to 200 Amps � 0 to 100 Amps -�Y=�-
Street Ltg./Traffic $ig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Outline Ltg. Xfmc �5 : 5 �- `
Alarm/Remote Control
Swimming Pool
I hereb certi that 1 ins ted the electrical ins�allation described herein on the dates stated
Irrigation Boom ` � Roughan Date
$pecial Inspection
Investigative Fee F�� � – - � �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MON HS.
OFFICE USE ONLY This requesf void 1 8 monfhs from validafion dafe prinfed in fhis box.
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Request DaTe Rough-in inspecfion required? ❑ Yes ❑ No Inspection Other Than Rough-In: eady Now ❑ Will Call
.� j (You must call fhe inspector when ready) Date Ready: �
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
1ob Address �Sheet, Box, or Roufe No.) Cify ' Zip Code
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Secfion No. Township Name or No. � Range No. Fire No. County
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Occupant Phone No.
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Power Supp ier Address
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Elecfrical Conhacfor (Company Name) Conhacfcr License No. Masfer Lic. No. (Plonf Elect. Only�
DEFEti'DH�LE ELECTRf!` ��' ���,°r � L> '%�- �,���:-�: _� ��.
ai n d �d+�"bn ' �jPGIC�1w�Y1Pp.,�orr�i�ednstallation� .
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Aufhorized Signature (Conha wner Performing Install ion� Phone No.
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EB-00001 A-1 1 S/96 STATE OARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY