P - 83426REQUEST FOR ELECTRICAL tNSPECTION '�"-
�1+�' Minnesota State Board of Electricity
, f V�- 0 81 � 1821 University Ave., Rm. S-128, St. Paul, MN 55104
� Phone (612) 642-OS00
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 request. Enter remarks in this space and on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Request will nof be accepted without the cor�`cf tee��
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Streef Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator �NSPeCTOR�s use oN�v TOTAL
Sign/Outline Ltg. Xfmr. -�
Aiarm/Remote Control �,
Swimming Pool
I hereb certi that I ins ted the elechical insrollation described herein on the dafes stafed
Irrigafion Qoom - Rough-In D� /�_
Special I ��
Investigative Fee Final oaJe`' Za— �
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TFIIS INSTALLATION MAY BE ORDERED DISCQNNECTED tF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validation date printed in fhis box.
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PLEASE PRINT OR TYPE
Request Dafe Rough-in inspection required$ ❑ Yes No Inspecfion Ofher Than Roughan: ❑ Reody Now Will Call
`/ �/6 ��� �You musf call fhe inspector when ready� DaTe Ready:
I, � licensed contractor ❑ owner hereby request inspection of the above electrica! work at:
Job Address �Srreet, Box, or Route No.) Ciry � Zip Code
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Section No. Township Name or No. Range No. Fire No. County
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Occupanf Phone No.
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Power Supplier Address '
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Elec}rical Confracfor (Company Name� Conhacfor License No. Master Lic. No. �Planf Elecf. Only)
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Mailing Address �Confracfor or Owner PerForming Installafion)
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Authorized Signature �Contractor or Owner Performing Insfallation) Phone No.
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EBA0001 A-11 8/96 STA BOAR COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY