P - 83637- . REQUEST FOR ELECTRICAL INSPEGTI(3N �
5��} - 2 7 2 Minnesota State Board of Electricity
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 Con : Htg. Equip. 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 the white copy only.
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Calculate Inspecfion Fee - This Inspe
Other Fee
Mobile Home Park Stall
Street Ltg./Traffic Sig.
Tra nsformer/Generator
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimmina Pool
m Request will not be accepted without the correc► fee:
# Service Entrance Size Fee # Circuits/Feeders Fee
0 to 200 Amps 0 to 100 Amps 1�.�?°
Above 200 Am s Above 100 Amps
INSPECTOR'S USE ONLY �, r� �� . T � � - ��
l �
that I ins ted the electrical installation described herein on the dates stated
Date
Investigative Fee -
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 monfhs from validaficn dafe prinfed in ihis box.
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I III) II III II (I� II III II II I III II II) II III I��I
* � 5 1 4 2 7 2 4* PLEASE PRINT OR TYPE ��
Requesf Date Rough-in iospecfion required2 ❑ Yes_. o Inspecfion Olher Than Rough-In: �,Ready Now ❑ Will Call
g�+ �^r � (You must call the inspector when ready) Dafe Ready:
i, �licensed contractor ❑ owner hereby request inspection of the above electrical work at:
1ob Address �Street, Box, or Route No.) City Zip Code
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SecFion No. Township Name or No. Range No. Pire No. Cnunw
Occupanf
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Power Supplier
AROW E�@CtftCSi
Elechical Confractor �C����p►.
or
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Phone No.
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Address
vOtl DCS
nan Contractor License No.
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rming Installation)
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t[� Phone No.
� �5�.�-�76�
Y COPY