P - 81084REQUEST FOR ELECTRICAL INSPECTION
.'S.i�V �-17 2 � Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �
Phone(612)642- 0 "��
Home Duplex Apt. Bldg. Other: , New Addn
Commercial Industrial Farm � i SD �� Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" ab�e+�e�o/k cQvered by this request. Enier remprks in this space and on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepied without the cornect fee:
Other Fee # Service Entrance Size Fee # Circuets/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
$treet Ltg./TrafFic $ig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOT ,`O L�D
Sign/Outline Ltg. Xfmr. �� •��
Alarm/Remote Control /,
Swimming Pool � , S'�
I hereb certi thaf I ins the electrica ' stallafion described herein on the s
Irrigation Boom RooaMo -�-c�
Special Inspection
Final p �
�mestigative fee 6 ��p'Z -
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This req�est void 18 months from validation date printed in this box.
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PLEASE PRINT OR TYPE
Requesf Dafe Rou h-in ins on r uired? Yes
g pecti eq ' ❑ No Inspection Olher Than RougMn: ❑ Ready Now Will Call .
�� �� g � �You musi call fhe inspecYOr when ready) Dafe Ready:
I, ❑ licensed controctor owner hereby request inspection of the above elechical work at:
Job Address �Street, Box, or Route No.) � City Zip Code
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Section No. Township Name o� �o. Range No. Fire No. ounty
Occupant
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Power Supplier Add�
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Elec}rical Confrac (Compony Name) �
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Moiling Address �Confractor or Owner Perfwming Installation)
sya? Cas� a�ec� n er� �
Aufhorizec;SignaNre �Conhacfor or Owr�r Perfoyping Installafion
Phone No.
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License No. Master Lic. No.
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Phone No.
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY