P - 82710RE�UEST FOR ELECTRICAL INSPECTION ����� Ee-0000i-os
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��.� ::�`% �f�� "X" Be/ow Work Covered by This Request °� �
New Add Rep. Type of Building Appliances Wired Equipment Wired
Home Range Temporary Service
Duplex Water Heater Electric Heating
Apt. Building Dryer Load Management
Comm./Industrial Furnace Other (Specify)
Farm Air Conditioner
Other (specify) Contractor's Remarks: ats.�.� �r r� n�d� �
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Compute Inspection Fee Below:
# Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Swimming Pool 0 to 200 Amps 7 0 to 100 Amps
Transformers Above 200 Amps Above 100 Amps
Si nS Inspectors Use Only: TOTAL
Irrigation Booms 30. ��
S ecial inspection
Alarm/Commu THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT
Other Fee '. COMPLETED WITHIN 18 MONTHS.
I, the Electrical inspector, hereby Rough-in �D2at_ _�
certify that the above inspection has Final Date
been made. � � _
OFFICE USE ONLY
This request void 18 months from
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Request Date � Fire No. Rough-In Inspection Required I ction Other Than RgY9h�tn
a_J �, �� (You must nspectw when reatly) � Ready Now �Will Notify Inspector
� es ❑ No Date Read
I I.�'fi ensed contractor ❑ owner hereby request inspection of above electrical work at:
Job Address (Street, Box or Route No,) ���y
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Section No. Township Name or No. Range No. County
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Occupant(PRINT) Phone No.
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Power Supplier Addre
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Electrical Contractor (Com any Name)
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Mailing Address (Contraclor or Owner Making I stallation)
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Autho�ed Sigr�pture (ContractodOwner Mal� Installation)
MINNESOTA STATE BOARD OF ELECTF
Griggs-Midway Bldg. - Room 5-128
7821 University Ave., St. Paul, MN 55704
Phone(612)642-0800
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Contractor's License No.
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Phone Number
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