P - 83362REQUEST FOR ELECTRICAL INSPECTION
5 3`� ��� 1 Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �:
� ► Phone (612) 642-0800 � Q
• Home Duplex Apt. Bldg. Other: C,� New Addn
Commercial Industrial Farm s, �L• ` Remod e ir
Air Cond. Htg. Equip. Water Htr. Lood Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. fnfer remarks in this space and on the back of the white copy only.
Calculate Inspection Fee - This Inspection Requesf will not be accepted without ihe correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall to ps ,�j_ 0 to 100 Amps
Street Ltg./TrofFic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S uSE o�`� TOTAL /
Sign/Oudine Ltg. Xfmr. j%��j�c.� �(o•��
Alarm/Remote Conhol
Ihor �
Boom
Date
THIS INSTALLATION MAY BE ORDERED DIS�ONFECTED IF NOT COMPLETED WlTH1N 18 MONTHS.
OFFlCE USE ONLY This request void 18 months from validation date printed in this box.
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* � 5 3 � 5 3 7�%1� PLEASE PRINT OR TYPE
Req��t Ro h-in ins on r uired?
ug pecli eq ❑ Yes Inspection Other Than Rough-In: ❑ Reody Now ❑�II Cdl
� '' � (You must cail Ifie inspecfor when ready� Dote Ready:
I, ❑ licensed confroctor �owner hereby request inspection of the above elechica) work at:
Job Addreu (Sheet, Box, w Roule No.� Ci1y Zip Code
.�a ,� yr� �� ,c�,� � ��e � � l � y ss �i3 z
Section No. Township Name or No. Range No. Fire No. Counry
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Occupant Phone No.
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Power Supplie� Addreu �
n�5 � %L�t j �i.
Electrical (Company Name) Conhactor License No. Master Lic. No. (PIaM Eleci. Only)
w,v�,
Mailing Address (C�ellllpctor or Owner Perlorming Installotion) .
o= er P ing I stallatjpAJ Fi (�• � C� Phone No. r
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'vlJV,y` ��?G��S �'
STATE BOARD PY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY