P - 80746� REQUEST FOR ELECTRICAL INSPECTION
8�-� ��� Q � Minnesota State Board of Electricity
`� 1821 University Ave., Rm. S-128, St. Paul, MN 55104 -
Phone(612)642-0800 "�'
Home Duplex Apt. Bldg. Other: New ddn
Commercial Industrial Farm Remod Re aii
Air Cond. Htg. Equip. Water Htc 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 Inspecfion Fee - This Inspection Requesf will not be accepfed wiihouf the correct fee:
Other Fee # Service Entrance ize Fee # Circuits/Feeders Fee
Mobile Home Park Stall � 0 to 00 Amps ,Q(� 0 to 100 Amps p. �(7
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR�s usE oN�v TOTA
Sign/Outline Ltg. Xfmr. .�
Alarm/Remote Confrol
Swimming Pool
I hereb certi that I ins the e ical installa�ion described herein on the dates stated
Irrigation Boom RougMn Da
$peciallnspec y `��g
Final D
Investigative Fee Qt�� �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
._. OFFICE USE ONLY This request void 18 months (rom validafion dafe prinfed in fhis box.
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PLEASE PRINT OR TYPE
Reqtrest Date � Rough-in inspecfion required$ ❑ Yes No Inspecfion O�er Than Rough-In: eady Now ❑ Will Call
9 �You must mll the inspector when ready) Date Ready:
I, �licensed contractor ❑ owner hereby request inspection of the above electricol work at:
Job Address (Sheet, Box, or Route No.) Ciy Zip Code
L��"`�1 A. s 1 R^ f i ["� _•_ .
Power
or No. � Range No. � Fire
Phone No.
Conhacror (Compony Name�� � I Conhacror License No. Masfer Lic. No.
(Conhocfor or Owner
STATE BOARD COPY - SE€ INCyy�"*�ONS ON BACK OF 17E6�OW COPY
No.