P - 77731REQUEST FOR ELECTRICAL INSPECTION
Q(� �� 3 a 5 Minnesota State Board of Electricity -
<<a �� • 1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
Home Duplex Apt. Bldg. Othe � O New Addn
Commercial Industrial Farm , b emod Re air
Air Cond. Htg. Equip. Water Htr. Load Mg . Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space anc� on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Request will nof be accepted withouf the correc► fee:
Other Fee # Servi Entrance 'ze Fee # Circuits/Feeders Fee
Mobile Home Park Sfall 0 t 00 mps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL�', ��
$ign/Outline Ltg. Xfmr.
Alarm/Remote Conirol
Swimming Pool
hereb certi that I ins ected fhe electrical insfallation described herein on }he dotes stated
Irrigation Boom oogMn D
Speciallnspection �� �"�
Final D
Investigative Fee ��� � ���
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHI 1 ONTHS.
QFFICE USE ONLY This request void 18 months from wlidation date prinied in fhis box.
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PLEASE PRINT OR TYPE
Requesf Dafe � Rough-in� inspection required? ❑ Yes ❑ No Inspecfion Other Than Rough-In: ❑ Ready Now Will Call
.� , r� �Yoy must call the inspector when ready) Date Ready:
I, ❑ licensed contractor owner hereby request inspection of the above elecfrical work at:
1ob Address �Sfreef, Box, or Roufe No.) City Zip Code
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Secfion No. Township Name or No. Range No. Fire No. County
o .�h�ka
Occupa Phone No. �
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Power Supplier Address (� � 1
Lt, •
Elechical Conhactor (Company Name) Contractor License No. Master Lic. No. �Plant Elecf. Only�
0 �11'
Mailing Address (Conkacfor or Owner Performing I stallafion)
S� St 4. �'Q,�er� a�r, S T N�
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BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY