P - 82591������i�UEST FOR ELECTRICAL INSPECTION ���
7�f.. ���� � Minnesota State Board of Electncity �`3
_. `J 1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800 '��'
Home Duplex Apt. Bldg. Other: New Addn
Commercial 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 request. Enter remarks 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 occepted wiihout the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 00 Amps . 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Outline Ltg. Xfmr. '
Alarm/Remote Control
Swimming Pool
I hereb certi fhaf I ins ected the electrical ins}allafion described herein on the dates stated
Irrigation Boom Rough-In D �
Special Inspection VT� �- ��
final �
Investigative Fee �' � a
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 1 8 monfhs from validation date prinfed in fhis box.
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PLEASE PRINT OR TYPE
Request Date Rou h-in ins tion re uired? es
/�y�{ 9 P� q ❑ No Inspection Other Than Rough-In: ❑ Ready Now Wil) Call
(p '� �' �(i' V �You musf call the inspector when ready) Date Ready:
I, ❑ licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sheet Box, or Ro�te No.) City �/ � Zip Code
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Section No. Township Name or No. Range No. Fire No. Co
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Occupani Phone No.
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Confractor �Company Name)
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�d ress (Contracror or Owner
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d Signafure (Conhacfor or O�
Confractor License No.
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BOARD COPY - SEE INSTRUCTIONS ON BACK OF
Master Lia No. (Plant
Phone No.
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COPY