P - 83931REQUEST FOR ELECTRICAL INSPECTION -
�� '1 _ 6 8 9 Minnesota State Board of Electricity
. 1� 1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
Home Duplex Apt. Bldg. Other: � p New Addn
Commercial Industrial farm �,�v 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 this space and on the back of ►he white copy only.
Calculate Inspection Fee - This Inspection Request will not be accepted wiihout ihe correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Skeet Ltg./TrofFic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL� C�
Sign/Oudine Ltg. Xfmr.
(�i
Alarm/Remote Confrol
Swimming Pool
I hereb certi that I ins the elechical insmllation described herein on the dates stated
Irriaation Boom o,,,,,.��„ n,.b
� Investigative Fee �ii tJ,�J'�J �� � � pC /Q �Z
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This request void 1 B montfis (rom validation daM prinfed in ihis bOx.
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quest Dafe Rough-in inspecfion required$ ❑ Yes No Inspection 01her Than ough-In: Ready Now ❑ Will Call
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(You musf call the inspector when ready� Dafe Ready: �Z�
� licensed contractor ❑ owner hereby request inspection of the above electrical work at:
idress �Sheet, Box, or Rou� No.� \� � City ' , Zip Cod` e_ Q^
3 , �`��'3
n o. Township Name or Range No. Fire No. Couny /� �^ �
Occupant
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P er u� � r �� �. Address
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Elechical tracfor ompan Na e� /� Conl
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Mailing Address (Conkacfor or Owner Performing Installa' n�
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Aufh�orizc�nature �Conkacfor or Owner Perfo^ ng Insfallafion) a �
Phone No. � � � �7 ' r
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License No. Mast r Lic. No. (Piant Elecf. Only)
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