P - 81010� RE(�UEST FOR ELECTRICAL INSPECTION °��
r� L, m� Z� � Minnesota State Board of Electricity � e
� `l 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 ihis space and on the back of ihe white copy only.
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Calculate Inspecfion 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 20C Amps �,j;� y'' 0 to 100 Amps ��D'=
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator iNSPeCTOR'S USE ONLY TOTAL
Sign/Outline Ltg. Xfmr. � . �
Alarm/Remote Control -
Swimming Pool
I hereb certi that I ins cted the electrical installation described herein on the dafes sfafed
Irrigation Boom Rough-In Dale
Speciaf Inspecti • i
Final Da
Imestigative Fee �� -�
THIS INSTALLATION MAY BE ORDERED DtSCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 months from validation date printed in this box.
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PLEASE PRINT OR TYPE
Request Dafe Rough-in inspection required? ❑ Yes No Inspecfion Other Than RougMn: ❑ Ready Now � WiN Call
!O �(�' 9 (You must call the inspector when ready) Date Ready:
I, �licensed contractor ❑ owner hereby request inspection of the above electrical work at:
.bb Addreu (Shcet, Box, or Route No.) Ciy Zip Code
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Section No. Township ame or No. nge No. Fire No. C nry�J
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Occu nt Phone No.
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Power Supplier Address . �
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Elechical Conhactor (Company Name) �onhacfor License No. Masfer Lic. No. (Plant EIeM. Only)
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Mailing Address (Conhacfor or Owner Performing Insfallafion�� �� �
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uthorized Signature �Con r or e ing Installatiord` Phone No.
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E -11 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY