P - 83093REQUEST FOR ELECTRICAL INSPECTION �
6 7 4�'a ?� � Minnesota State Board of Electricity
� �� 1821 University Ave., Rm. S-128, St. Paul, MN 55104
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Phone (612) 642-0800 '���
Home Duplex Apt. Bidg. 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 ihis 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 accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Sireet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Outline Ltg. Xfmr. t S SO
Alarm/Remote Control
Swimming Pool
I hereb ceAi that I ins the elechical installaKon described herein on the dates sfated
Irrigation oo ' Ro�Mn par�
Sp2cial I ' f
Investigative Fee F�� �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
I IIII II III I III I OFFICE USE ONLY This requesf wid 18 months from validafion date pri;ted in ihis box.
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PLEASE PRINT OR TYPE
Request �'� �� � Rou h-in ins ion r uired?
g pec( eq ❑ Yes o Inspecfion Other Than Rougffln: ❑ Ready No� Will Call
� �You musf call the inspecfor when ready) Dafe Ready:
I, �licensed conhactor ❑ owner hereby request inspection of the above elechical work at:
Job Address (Sheef, Box or Route No.� Ciy Zip Code
o� i���e . fr�� S 3�
Secfion No. Township Name or No. Range No. Fire No. County
Occu nf
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Elechical Conhactor (Company Name) N'„r. Conhactor License No.
MNEMM.�G�T t... ��
MaJmg Addr _ _ _ e N Ellation) ��
ner Pertormi� Insfallafion) /� �(]/� � Phone No.
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY