P - 82738� RE(�UEST FOR ELECTRICAL INSPECTION -
�j � l� �� g 9 Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
Home Duplex Apt. Bldg. Other: New Addn
Cammercial Industrial Farm Remod Re air
Air Cond. Htg. 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 baek of the white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stail 0 ro 200 Amps 0 ro 100 Amps
Sheet Lfg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOT�`��
Sign/Oudine Ltg. Xfmr. v t'�
Alarm/Remote Conkol
Swimming Pool
I hereb certi thW I ins !he eleclrical insmllafion described herein on the dafes stated
Irriqation Boom o,.,�.i.,., n,.,�
� THIS INSTALLATION MAY BE ORDERED DISCONNECTED_1F NOT COMPLETED WITHIN 18 MO�fiS.
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OFRCE USE ONLY This requesf void 18 months from validation dafe printed in this box.
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* 0 5 5 9 3 8 9 2* P�EASE PRINT OR TYPE
Request Dafe Rough�+n inspecKon required$ ❑ Yes No Inspecfion Other Than RougMn• Ready Now ❑ Will Call
(You must call the inspecror when ready� DaM Ready: ��'
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sheet, Box, or Rou o.) � Ciy � Zip Code
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Seclion o. Township Name or No. Range No. Fire No. C ny
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Phone No.
57�1�
Confracror License No. I Master Lic. No.
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�Conhaclor or Owner Performing Installation) �
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dure onhacfor or Owner Pe irg Installation� � Phone No.
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�9 STATE BOARD PY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY