P - 83370REGIUEST FOR ELECTRICAL INSPECTION ��
6��~ 0 3 9 � Minnesota State Board of Electricity
L 1821 University Ave., Rm. S-128, St. Paul, MN 55104 �:
� Phone(612)642-0800 "��
ome Duplex Apt. Bldg. Other: New Addn
Commercial Industrial farm Remod Re air
Air Cond. Htg. Eq�ip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. En►er remarks in this space and on the back of ihe white copy only.
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Calculate Inspection Fee - This Inspecfion Request will not be accepted wiihout the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps i 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR's USE ON�v TOTAL r
Sign/Outline Ltg. Xfmr. �J���
Alarm/Remote Conirol
Swimming Pool
I her certi that I ins the elechical installation described herein on the dales stotad
Irri9ation Boom RougMn Dore
Special Inspe�tion
Final
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18�MONTHS.
OFFICE USE ONLY This request void 18 months from validation date printed in this box.
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LEASE PRINT OR TYPE
Request Date Rough-in inspeclion required$ ❑ Yes No Inspeclion Other Than RougMn: Ready Now 0�11 Call
li` g �You must call the inzpec�or when ready� Dafe Reody:
I, �licensed contractor ❑ owner hereby request inspection of the above elechical work at:
Job Address (Strcet, Box, or Ro�fe No.) City Zip Code
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Secfio� No. Township Name or No. Range No. Fire No. Co
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Occupant Phone No.
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Power Supplier Address �
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Elechical Confrac or (Company Name� Confracfor License No. Master Lic. No. (PIaM Elecl. Only)
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MaiHng Address (Conhactor or Owner Performing Inslalla6on� /1 � D�
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Auth ' ed Signature (Conhacfor or Owner Performing Installotion) ������ Phone No. �
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E&00001 A-1 1 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON SACK OF YELLOW COPY