P - 84463' ' REQUEST FOR ELECTRICAL INSPECTION -��..
4� J- 9 3 2 Minnesota State Board of Electricity
1821 Universiiy Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
Home Duplex Apt. Bldg. Other: New Addn
Commercial Indushial Farm Remod Re air
Air Cond. Htg. Equip. Water Fitr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" aboveI the work covered by fhis requesi. Enter remarks(in thi�s space and on ihe back of the white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted wifhout the correci fee:
Ot er Fee # Servi e Entranc Size �-'`Fee 1 # Circuits/Feeders "�ce
Mobile Home Park Stall 0 to �0 Amps / 0 to 100 Amps s°
Street Ltg./Traffic Sig. Above 200 Am = Above 100 Amps ,"`T
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Outline Ltg. Xfmr.
Alarm/Remote Confrol
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Swimming Pool ._..
I hereb certi Ihat I ins ed ihe elecfrical insfallafion described herein on s
irrigation B � � Rou h-In
9 pa�
$pecial Ins
Final
Investigative Fee �°�f 2 C_
THIS INSTALLATI6N MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validafion dafe printed in this box.
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Requesf Date Roughin inspection required$ ❑ Yes ❑ No Ins on O�e� Than Rou Mn:
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�You musf call fhe inspecbr when ready) pafe R¢ady.
I, �licensed conhactor ❑ owner hereby request inspection of the above elecfrical work at:
Job Addreu (Sheef, Box, or Route No.� City Zip Code
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$eclion No. Township Name w No. Range No. Fire No. County
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Occupant Phone No.
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Power Supplier Address
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Eleclrical Contractor (Company Name� Conkactor License No. MasTer Lic. No. (Plant Elect. Only�
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ili� Address �Conhaclor or Owner PerFor ing Insfallafion)
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A n onk r er Performing Insfallation Phone No.
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E&000p1A-11 8 6 STATE BOARD COPY - SEE INSTR CTIONS ON BACK OF YELLOw c�av