P - 84684/�(�r� REQUEST FOR ELECTRICAL INSPECTION �.
4 5 9�"' �F J L Minnesota State Board of Electricity
1821 Universiry Ave., Rm. S-128, St. Paul, MN 55104 �.
� Phone (612) 642-0800
Home Duplex Apt. Bldg. Othe ew Addn
Commercial Industrial Farm Remod Re ir
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above ihe work covered by is re ue t. En remarks in this s e and on the back of fhe white copy only.
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Calculate Inspection Fee - This Inspeciion Request will noi be accepfed withoui the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Streef Lig./Traffic $iq. Above 200 Am s Above 100 Amps
Transformer/Generotor INSPECTOR'S USE ONLY TOTA �(��
Sign/Oudine Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
I hereb certi that I in the elechical installation described herein on fhe dates stafed
irrigation Boom RougMn pa�e
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MO�
OFFlCE USE ONLY This request void 18 months (rom validation date printed in this box.
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PLEASE PRINT OR TYPE
R uesf Dafe Rou h-in ins fion r uired?
� 9 P� eq ❑ Yes Inspecfion O�er Than RougMn: ❑ Ready No 'II Call
�`(ou must call the inspeclor when ready) Date Ready:
I, icensed contractor ❑ owner hereby request inspection of the abave elechical work at:
lob Address (Sheef, Box, or Roule No.� Ci • Zip Code
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Section No. Township Name or No. Ronge No.
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GC�Beci
Power Supplier Address
Mailing Addreu �Conhacfor or Owner
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Aufhorized Sipnafure Conhacfw or O�
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Phone No.
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ConharTor License No.
G° A�D d =!Z.
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25238
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Master
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Phone No.
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