P - 80824r► REGIUEST FOR ELECTRICAL INSPECTION ��°-
Q��� m 5 g 1 Minnesota State Board of Electricity �
�` � � 1821 University Ave., Rm. S-128, St. Paul, MN 55104 �`
Phone (612) 642-0800 '���
ome Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re air
nd. : Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this requesi. Enter remarks in this space and on the back of the white copy only.
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Calcvlate Inspection Fee - This Inspection Request will not be accepted without ihe correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps $
Street Ltg./Traffic $ig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TO�AL I!� 50
Sign/Outline Ltg. Xfmr.
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Alarm/Remofe Confrol
Swimming Pool
I hereb certi that I ins ted the eleclrical installation described herein on the dates stafed
Irri9ation BOOm Rough-In � � Date
Special fnspecti F�nal
Investigative Fee �'-�
THIS INSTALLATION MAY BE ORDERED DISC NECTED IF NOT COMPI.ETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validation date printed in fhis box.
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PLEASE PRINT OR TYPE
Request Date Rougifin inspeclion required$ ❑ Yes o Inspection Ofher Than Rough-In: eady Now ❑ Will Call
g�Z� �� (You m�st call the inspector when ready) Date Ready:
I, �licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sheet, Box, w Route No.) Ciy Zip Code
45 �_ �o� �� , .. .. . ,�� �a:.►�t�... 5 S�tZ�
No. � Township Name o� No. � Range No. � Fire No.
Occupant
Power
Phone No.
Contracror (Company Name) I Conhacfor License No. _ I Master Lic. No.
� � — - '
� Address (Conhactor or Ow�r Pe�formi� Installafion{
5 Z5 t�l�e.uo�cl��a�.�t.t�2.:�►I���l�n l�i� v�'L1l�Z-
zed Signature (Conh«for or Owner PerForming I�j � � f" Phone No. .
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY