P - 82451REQUEST FOR ELECTRICAL INSPECTION
U�{y C O-�� ry � Minnesota State Board of Electricity
i� V 1 1821 University Avenue Suite S-128, Saint Paul, Minnesota 551044993
' (651) 642-0800 www.electricity.state.mn.us
Home Duplex Apt. Bldg. Other: Ne�
Commercial Industrial Farm Rerc
Air Conditioner Hfg. Equip. Wafer Htr. Load Mgmt. Other:
Dryer Range Elec. Heaf Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the whi�
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Repair
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Calculafe Inspeciion Fee - This Inspection Request will not be accepted without the correct fee:
Ofher Installations Fee # Service Entrance Size Fee # Circuits / Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg. / Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TO�T1AL
Sign / Outline Ltg. Xfmr. I D• �
Alarm/Remote Control
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I hereb certi that I ins ected the electricai installation described herein on the dates sfated:
Irrigation Boo Rougffln _ , // Da
$pecial Inspe "' � �' � � d
Final Da
Investigative Fee ���--�
THIS INSTALLATION MAY BE ORDERED DISCONN TED IF NOT COMPLETED WI HIN 18 MONTHS.
OFFICE USE ONLY This request void 1 S months from validation dafe printed in fhis box.
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PLEASE PRINT OR TYPE
Request Date Rough-in inspection required? es ❑ No Inspection Olher Than Rough-In: ❑ Ready Now ��ill Call
.� ���� (� � You musf call the inspecror when ready Dafe Ready:
I, �censed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address �Sheef, Box, or Route No.) p City � Zip Code
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Secfion No. Township Name or No. Range No. Fire No. Co ty � �
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Occupanit /� / �� Phone No.
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�r Supplier ^ � � � ` Address
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Electrical Confracfor / Company Name Contractor Litense No. Masfer Lic. No. �Planf Elecf. Only�
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Mailing Address (Conhacror, Company or Owner Performing InsMllofion)
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Aulh Signature (C nhacfor, Com r PerForming Insfallafion) Phone Number
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EB-00001A-12 5H999 STATE B COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY