P - 83136REQUEST FOR ELECTRICAL INSPECTION �
6������ � Minnesota State Board of Electriciry
1 1821 University Ave., Rm. S-128, St. Paul, MN 55104 �:
� Phone(612)642-0800
Home Dupiex Apt. Bldg. Other: New Addn
Commercial Industrial farm Remod Re air
Air Cond. Htg. Equi . Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this spoce 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 correcf fee:
Other Fee # Servi trance ize Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 200 mps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 00 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Outline ltg. Xfmr. .7 ! .�G'I
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins the elecfrical insfallation deuribed herein on the dotes stated
Irrigation Boo Rough-In Da�e
Special Insp
Final D
Investigative Fee
THIS II�STALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE U8E ONLY This roquesf void 18 monlhs from validation dafe printed in this box.
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PLEASE PRINT OR TYPE
Requesf Dafe Rough-in inspection required$ ❑ Yes No Ins fion Other Than Rou h-In:
P� g ❑ Ready No Will Call
�� �'�� r'ou musf wll Ihe inspecfcr when rea Dafe Ready:
I, icensed contractor ❑ owner hereby request inspeetion of the above elechical work at:
1ob Address (Streef, Box, or Roufe No.� City . � Zip Code
S� � � �
Section No. Township Name or No. Range No. Fire No. C unty
Occupant Phone No.
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Power Supplier Address
Electrical Conhacror �Company Name) Conhacfor License No. Master Lic. No. (Plant Elecf. Only)
s �� ! D 6 !�
Mailing Address (Conhacfor or Owner Performing Installafion) / � �
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Auf orized Signature �Conhacior r Owner Performing Installation) '�� • Phone No.
1 A- 1 8/96 v 3�-- �3/
STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY