P - 83855REQUEST FOR ELECTRICAL INSPECTION
4(] ���l �� � Minnesota State Board of Electricity
J � t� 1821 University Ave., Rm. S-12$ St. Pau"1`, MN 55104
, Phone (612) 642-0800 ,.
ome Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod e air'
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"Y." above the work covered by this request. Enter remarks in this space and on the back of the whiie copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted without ihe correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Ar
Transformer/Generator INSPECTOR'S USE ONLY TOT,
Sign/Outline Ltg. Xfmr. (
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ected fhe electrical insiallation described herein on fhe date
Irrigation Boom Rough-In �a�e
Soecial Ins�ecti •) �') __
5
srated
Fee
� Investigative Fee � " c� � (� /(' � --� IT—�`� � �'
`THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WI'fHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 monfhs from validation date printed in fhis box.
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Request Date R h' ' t ' dz ❑ Yes o Ins ection Other Than Roughan: eady Now 0 Will Call
//�� oug -in mspec ion reqmre . p
y� � 3 Q.�/, (You musf call the inspecfor when ready) Dafe Ready:
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I, �icensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sireet Box, or Route No.) City Zip Code
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Secfion No. Township Name or No. Ranqe No. Fire No. Co
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EI ckical Conhacfor (Company Name) (
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Mailing Add ss o�hactor or Owner Perform' Insfallatio �
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A ' e i o hactor or Owner Performing Installation� ��
Phone No.
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License No. � Master Lic. No. (Plant
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Phone No.
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J BACK OF YELLOW COPY