P - 80339�
,U-�9�-556 �
REQUEST FOR ELECTRICAL INSPECTION �
Minnesota State Board of Electricity 3
1821 University Avenue Suite S-128, Saint Paul, Mi��esota 55104-2993 -
(651) 642-0800 www.electricity.state.mn.us
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Repair
Air Conditioner Htg. Equip. Water Htr. 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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Cal 1 te Ins ection Fee - This Ins ection Re uest wil(not be acce ted wi�hout the correct fee:
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Other Installations Fee # Service Enhance Size Fee # Circuits / Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg. / Tra�fic Sig. Above 200 Amps Above 100 Am s
Transformer/Generator INSPECTOR'S USE ONLY TOTAL 1., `�
Sign / Outline Ltg. Xfmr. P� v �
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ted the elechical installation described herein on the dates stated:
Irrigation Boom Rouah-In Dare
-r--.— ...-r--"- Final � :r � ... I Dafe �(/ ,�r�,� >��P) I
Investigative Fee 7"" ep� �"
THIS INSTALLATION MAY BE ORDERED DISC TED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months 4rom validotion date printed in ihis box.
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PLEASE PRINT OR TYPE
Request Date Rough-in inspeciion required6 ❑ Yes ❑ No Inspecfion Ofher Than Rough-In: � eady Now � Will Call
�"�?.� QQ You musf call the inspecror when ready Date Ready:
I, �licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
1obQ�ddress �Sheet Box, or Route No.} Cily /' Zip Code
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Elecfrical Conha br / Compan Name
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Mailing Address �Conjfmcfor, Com any or Owner Performing
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Il�or' ea5ignature (Confractor, Company or Owner Perfori
��rA 12 �1999 STATE BOARD COPY
Phone No.
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Conhactor License No.
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SEE INSTRUCTIONS ON BACK OF VELLOW COPV