P - 83499REQUEST FOR ELECTRICAL INSRE��..QN -
6 L+ �� r O� ° Minnesota State Board of Electricity
�J �� 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 Reaair
Air Con : 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
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of the white copy
Calculate Inspection Fee - Ihis Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps p2 0 to 100 Amps l?, a c-
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL,�'
Sign/Outline Ltg. Xfmr. �'� i ��
Alarm/Remote Control
Swimming Pool
I hereb certi thaf I ins fed the elechical insfallafion dexribed herein on fhe dafes sfafed
Irriaation Boom.� _ a.,��,.ti_i� Dar�
Investigative Fee �- ��� / '
TH1S INSTALLATION MAY BE ORDERED DIS ECTED IF NOT COMPLETED WITHIN 18 MONTHS.
._. OFFICE USE ONLY This request void 18 monfhs from validation date printed in this box. 'I
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PLEASE PRINT OR TYPE
Requesi Date Rou h-in ins ction r uired?
g pe eq ❑ Yes No inspecfion Ofher Than Rough-In: eady Now ❑ Will Call
� r� .� �� (You musf call the inspecfor when ready) Date Ready: ���
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
106 Address �Sheef, Box, or Route No.) City Zip Code
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Secfion No. Township Name or No. Range No. Fire No. Couny
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�Company Name)
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ihacfor or Owner Performing Insfallation)
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STATE
Phone No.
7�3-���
Confractor License No.
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SEE INSTRUCTIONS ON BACK OF YELLOW COPY