P - 82789REQUEST FOR ELECTRICAL INSPECTION °"
6� A,,, C Q� � Minnesota State Board of Electricity s
�' iL� v 1821 University Ave., Rm. S-128, St. Paui, MN 55104
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' Phone (612) 642-0800 "�'
Home Duplex Apt. Bldg. Other: New dn
Commercial Industrial Farm Remod air
Air Co 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 Inspecfion Fee - This Inspeciion Request will aot 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 ,(�
Sfreet Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSpECTOR'S USE ONLY TOITAL� �
Sign/Outline Ltg. Xfmr. �� �
Alarm/Remote Confrol
Swimming Pool
1 hereb certi fhat I ins fed the eleclrical installafion described herein on the dates sfated
Irrigation Boom , Roogl,-io �at�
Special Inspectio
Finat
Imestigative Fee � �� _ �G Z� l
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validation dafe printed in this box.
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PLEASE PRINT OR TYPE
Request Dafe Rough-in inspecfion required? ❑ Yes o Inspecfion Other Thon Rough-Ir!: Ready Now � Will Call
/`�Z7 �� (You must call fhe inspec�or when ready� Date Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Addre (Street, Box, or Route No.� C' Zip Code
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Section No. Township Name or No. Range No. Fire No. unty
Occu Phone No
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Power Supplier Addreu .
Electriwl Conhacjor (Company Name� �1 Cont�pcfor License No. Masier Lic. No. �Plant ElecF. Only)
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Mailing Addreu� nfracfor or Owner erforming Insfallahon� ��/ �—V
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u iz ' nature (Conhacfor er PerForming Insta IaKon� t Phone
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E&00001 1 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY