P - 83128REGIUEST FOR ELECTRICAL INSPECTION --�.
5 5 1�• 5 3 2 Minnesota State Board of Electricity
. 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 Mgmf. pther:
Dryer Range Elec. Heat Temp. Service
"X" above ►he work covered by this request. Enter remarks in this space and on the back of the white copy only.
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Calcvlate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entranc Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 00 Amps 0 ro 100 Amps
Street Ltg./Traffic Sig. Abo 200 Am s Above 100 Amps
Transfarmer/Generator INSPECTOR'S USE ONLY TOT L
Sign/Oudine Ltg. XFmr. '� ' 3 6
Alarm/Remofe Control
Swimming Pool
I her certi that I in the elechi installafion describad herein on the dates sfaied
Irrigafion Boom RougMn Da �
Special Ins
Final
Investigative F - s
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE UEE ONLY This nqusat vad 18 months from validation date printed in this box.
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* D S S L S 3 G� S* QLEASE PRINT OR TYPE
Request Da Rough-in inspeclion required$ ❑ Yes ❑ No Inspeclion Other Than RougMn: 0 Ready Now ❑�II Call
y� 4� �`/ou must call the inspeda when ready) DaFe Ready:
I, '�licensed contracror ❑ owner hereby request inspecfion of the above electrical work at:
Job Address (Shaet, Box, w Route No.) City J Zip Code
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Seclion No. Township Name w No. Range No. Fire No. Couniy n �
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Occupont/� , ` , .�,// Pha�e No.
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Power Supplier Address
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Eleclrical Conhacror (Company Name) Contractor License No. Master L"K. No. (Plont Elec1. Only)
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Mailing Address (Conhacro: or Owner PerForming Ins afion)
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A th� Signature Contra� Owner Pe�fwming Ins � �� �` /�/O
E&00001 A-11 8/96 �TATE BOARD COPY - SEE INSTRUC710NS ON BACK OF YELLOW COPY