P - 84742REf�UEST FOR ELECTRICAL INSPECTION -
� 0�_ � 18 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 Indusfrial farm Remod Re ir
Air Cond. Hig. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. $ervice
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
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Colculafe Inspeciion Fee - This Inspection Request will noi6 be dcepfed without the correcf fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps �0
Sheet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR�s use oN�r TOl/4L �
Sign/Oufline Ltg. Xfmr. �%�, �
Alarm/Remote Control
Swimming Pool
I hereb cerTi that I ins eded fhe eleckical insfallafion described herein on the da6es staled
Irrigation Boom Rough-In Da�e
Special Ins
Final �� ^
Investigative
THIS INSTALLATION MAY BE ORDERED NECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request wid 18 months from validafion date printed in this box.
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* O 5 O L 1 8 2 D* pLEASE PRINT OR TYPE
Requesf Dafe Rough-in inspeclion required? ❑ Yes o Inspecfion Olher Than RougMn: eady
❑ R Now i Call
'� �� �' l (You musf call the inspecror when ready) Date Ready:
I, icensed contractor ❑ owner hereby request inspection of the above elech�ical work at:
Job Addreu (Sheef, Box, or Roule No.) City Zip Code
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Seclion No. Township Nome or No. Range No. Fire No. County , /J _�a�.�
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Occu nt Phone No.
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Power Supplier Address
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Elecirical Conkaclor (Company Name) Conhacfor License No. Master Lic. No. (Plant Elecf. Only)
G�lc<<S � �'r.�f.�Z ��a 3 �
Mailing Addreu (Conhaclor or Owner Performing Insloll 'on)
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Aulhorized ' nature �Conhact r or QODper P�rforp�jpg�pstqupfiw�j ` Phone No.� ���
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