P - 83860RE(�UEST FOR ELECTRICAL INSPECTION
/� Q�` '']i Minnesota State Board of Electricity
�-} � O�.J V 1 m 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 Cond. 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 Inspection Fee - This 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 to 100 Amps � mm0
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY • TOTAL
Sign/Outline Ltg. Xfmr. f-i� d'l��rr. L�L �f �'(� f� 4�" ` D�
Alarm/Remote Control
Swimming Pool I hereb cen� rhar
Irrigation Boom Rough-In
Soecial I�specY'�n� f> > : � _. ,
ihe elechical installafion described herein
Investigative F� � � �! _ �`—�� l/ % /"—
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validation date prinied in this box.
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I IIII I) III (I �II �I (�I II III I II II III �� III I III) �a ��
* O 4 B O 9 6�% 9* PLEASE PRINT OR TYPE �' �
Request Date Rough-in inspecfion required? Yes ❑ No Inspection 01her Than Rouyh-In: ❑ Ready Now �Will Call
`� -�� —Q � (You musf call the inspecfor when readyJ Date Ready:
I, �licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Street, Box, or Route No.� City Zip Code
rl c�3 S �ks�N s� i� � F� ;� t�
Section No. Township Name or No. Range No. Fire No. Coun ^
Occupant
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Power Suo[
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Mailing /
Co�
A-
t? r
:tor (Company Name)
c�c � ��� �l� � `�
(Contractor or Owner%� rforming Installation�
�u� e/lss-��i ,�
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Phone No.
Conhacfor License No. Master Lic. No. �Planf Elect On
G�o /Co Q'c�
� c1 ST Gov.'s ��� ss�fi Le
Phone No.
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INSTRUCTIONS ON BACK OF YELLOW COPY