P - 80394REClUEST FOR ELECTRICAL INSPECTION -
���Q �; � Minnesota State Board of Electricity
V- 4 2 2 1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (672) 642-0800
� Home Duplex Apt. Bidg. Other: New Addn
Commercial Indusirial Farm emod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
D er Ran e Elec. Heat Temp. Service
"X" above the ork covered by this request. Enter re ks in this space and on the back of the white copy only.
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Calculate Inspec►ion Fee - This Inspec►ion Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # CircuitsfFeeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Sheet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR's uSe oN�Y TOTAL
Sign/Oulline Ltg. Xfmr. � 5�
Alarm/Remote Conhol
Swimming Pool
I here certi ihaf I i the elecfriml installation described herain on the do�es stated
Irrigation Boom Ro�Mn /� ��
Speciallns ti
Final D �
Investigative Fee � C/Z—�---- `�-
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS. _ _
OFFICE USE ONLY This requasf void 18 months From validafion daie prinMed in this box.
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PLEASE PRINT OR TYPE
Requesf Dafe Rou h-in ins ion r uired$ �es ❑ R N�II Call
g pecf' eq ❑ No Inspecfion Other Than RougMn: eady
_ 7—�} � �`(ou must cnll the inspector when ready) Date Ready:
I, �ensed contractor ❑ owner hereby request inspection of the above elecfrical work at:
Job Addreu (Street, Box, or Roufe No.) Ciy Zip Code
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Seclion No. Township Name or No. Range No. Fire No. Cou
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Occupant PFrone No.
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Power Supplier Address
Eleclrica o acror (Company NameJ Contracror License No. Master Lic. No. (Mant Elect. Onl�
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Mailing Address �Con r w Owner Performing Insmllafion)
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Authorized Sig ontracror or Ow Performing Installation� Phone No.
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EB00001 11 8/96 y�p� gppRD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW WPY