P - 81647REQUEST FOR ELECTRICAL INSPECTION
�" � � � � 1 � � Minnesota State Board of Electricity `3
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. Wafer Htr. Load Mgmt. Other:
Dryer Range Elec. Heot Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the v�hite copy only.
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Calculate Inspection Fee - This Inspection Request will noi be accepted without ihe correct fee:
Other Fee # Service Entrance Size fee # Circuits/Feeders Fee
Mobile Home Park Stall ' 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL �
Sign/Outiine Ltg. Xfmr.
Alarm/Remote Control
Swimming Pooi
I hereb certi that I ins ected the electrical installation described herein on the dates smted
Irrigation Boom _ _ RouaMn Date
Investigative Fee �li-""
THIS INSTALLATION MAY BE ORDERED DIS NNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 monfhs from validation date printed in this box.
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PLEASe PRINT OR TYPE
Requesf Dafe Rou h-in ins ion r uired?
g pect' eq ❑ Yes o Inspecfion Olher Than RougMn� eady Now ❑ Will Call
(You must call the inspector when ready) Date Ready:
I, �licensed conhactor ❑ owner hereby request inspection of the above electrical work at:
Job Address �Sheef, Box, or Route � Ci � e
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Secfion No. Township Nam! o� � Rang@ � � Fire . Co ��
of � ��
Phone No.
Power SupplierJ ('� /� n `� I Address
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Master Lic. No.
Mailing Address (Confracto or Owner P rforming Installation)
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Authorized Sipn �Conhaclor or Owner Pe r' Installafion) Phone No.
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INSTRUCTIONS ON BACK OF YELLOW COPY