P - 84482REQUEST FOR ELECTRICAL INSPECTION _
4`t �� 4 4 0 Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paui, MN 55104
� Phone (612) 642-0800
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industria) Farm Remod Re ir
Air Con . S Htg. Equip. Water Htr. 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 ihe white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accep►ed withoui the correct fee:
Other Fee # Service Entrance Size Fee # Circuits{Feeders Fee
Mobile Home Park Stall 0 to 200 Amps Z 0 to 100 Amps '
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR•s use ON�Y TOTAL �.
ine Ltg. Xfmr.
mote Control
� Pool
I
Boom
that I ins ted the electrical installation described herein on ihe dates stated
Dafe
. . Final ' Date ... ��
Investigative Fe _.c��--�_ ---`% Z`�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This requesf void 1 S months from validofion dafe printed in this box.
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* 0 4 4 2 4 4 � 4� LEASE PRINT OR TYPE
Request Date Rough-in inspecfion required2 ❑ Yes No Inspection O�er Than Rough-In: Ready Now ❑ Will Cai)
��� 97 �You musf call the inspec�or when ready) Date Ready:
I, licensed confractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sheet, Box, or RouTe No.� Ciy � Zip Code
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Secfion No. Township Name or No. Range No. Fire No. Counry
o«opo�r
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Power Supplier E
Eleclrirnl Conhactor (Company Name)
Harr; on E1 ri �
Mailing Address (Conhacfor or Owner PerForming Installation)
,qi�ol �
Phone No.
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Conhartor License No.
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BACK OF YEL
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