P - 82164REQUEST FOR ELECTRICAL INSPECTION °"E°�
7���� ��� � Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �.
` Phone (612) 642-0800 `�'
Home Duplex Apt. Bidg. 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 bc? �his request. Enier remarks in ihis space and on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Requesi will not be accepted wifhout the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps / 0 to 100 Amps L( °�
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Am s
Transformer/Generator INSPECTOR'S USE ONLY `I� TOTA
Sign/Outline Ltg. Xfmr. r' 0�
Alarm/Remote Confrol �� � G � � O �
Swimming Po
I hereb cedi that I ins ted the elechical installation described herein on ifie a s siated
Irrigation Boo RoogMo Dare
Special Inspection
Finel- ' Date
Investigative fee —2Z-- c3c�
THIS INSTALLATION MAY BE ORDERED DtSCONNECTED IF NOT t;OMPLETED WITHIN 18 MONTHS.
, OFFICE USE ONLY This requesf void 18 monfhs 6om validation date printed in this box.
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PLEASE PRINT OR TYPE �l ��
Request Date Rou Irin ins fion r u�red?
g pec eq ' ❑ Yes o Inspection Ofher Than Rough-In: eady Now � Will Call
,,� �"Q Q (You must call the inspeclor when ready) Date Ready: �
I, ❑ licensed contractor owner hereby request inspection of the ' I work at:
Job Address (Sheet, Box, or Route No.) iry Zip Code
5�93'G � � " ����� �►.� 2
Section No. Township Nome or No. Range No. ounty
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Occu�ni � Phone No.
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Power Supplier Address
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EI c Confracfor (Company Name ntraclor License No. Moster Lic. No. �Planf Elect. Only)
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Maili Address (Contractor or er Perfiormi I tallation�
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Authorized Si re onhacror or ner P rming Installafion� Phone No.
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EB-OOOOIA- 1 8/96 STATE BOARD COPY - SEE INSTRUC'iIONS ON BACK OF YELLOW COPY