P - 80360REQUEST FOR ELECTRICAL INSPECTION °'E
8 O� -1 � 5� Minnesota State Board of Electdcity
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �
` Phone (612) 642-0 ';��
Home Duplex Apt. Bldg. Other ����.�"� New Addn
Commercial Industrial Farm S 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 ►his space and on the back of the white copy only.
Calculate Inspecfion Fee - This Inspection Request will not be accep►ed withou► ihe correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Sta11 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR•SU�kN�v � • TOTAL /��
G_ � O_Fic.L.�
SignjOudine Ltg. Xfmr. �
Alarm/Remote Control
$Wimmin I herebvi certifv that I inspected the elechical inslpllation described herein on the dotes stated
Special Inspection — — '�'— � —
Final �
Investigative Fee
THIS {NSTALLATION MAY BE ORDERED DiSCONN CTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 months 1rom validafion date printed in fhis box.
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PLEASE PRINT OR TYPE
Requesf Dafe Rough-in inspection required� Yes ❑ No Inspection Other Than RcwgMn: eady
❑ R Now Wil! Call
(You must call fhe inspedor when ready� Date Ready:
I, ❑ licensed contractor wner hereby request inspection of the above electrical work at:
Job Address (SNeet, Box, or Route No.) Ciy Zip Code
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Secfion No. Township Name or No. Range No. Fire No. Coun
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Occupant Phone No.
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Power $upplier Address '
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Elecfrical Conhacfor �Company Name) Conkacfor License No. Master Lic. No. (Plant Elecf. Only�
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Nwiling Address (ConNacFOr or Owner Performing Installofion)
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Signafure (Con acfo or Owner Pe m g Insfallafion) Phone No.
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A-11 8/96 STATE BOARD COPY - SEE {NSTRUCTIONS ON BACK OF YELLOW COPY