P - 82833REQUEST FOR ELECTRICAL INSPECTION °'�
6 6 2-'�i� � O Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �
Phone (612) 642-0800
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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 ihe work covered by this request. Enter remarks in this space and on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepied without the correct fee: ���
Other Fee # Servi�e Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 0 Amps .�i� 0 to 100 Amps
Street Ltg./TrafFic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE OMLY OTI�I. �Q
Sign/Outline Ltg. Xfmr. ���+�
Alarm/Remote Conhol
Swimming Pool
I hereb certi thaT I ins the elecirical installofion dexribed herein on the dales stafed
Irrigafion Boom RougMn Date
Special Inspectio F�� p�y
Investigative Fee t ' 3`-Z.��
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 lNONTHS.
OFFICE USE ONLY This requeat v�oid 18 months 6om validafion date printed in Ihis box.
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PLEASE PRINT OR TYPE
R�=�j ^ y � Q Rou h-in ins tion r uired$ ❑ Yes o Ins _
O g pec eq �i01 pedion O�her Than Rou IFIn: eady Now � Will Call
`� �`fou must rnll ihe inspector when ready) Date Ready: g�/
I, �licensed confractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sheet, Box, or Roufe No.) City Zip Code
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$ection No. 7ownship Name or No. Range No. Fire No. County ^ � �
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Occu nt �,�n
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Power Supplier Address
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Elechical Conhacfor (Company Name) Contracror License No. Master Lic. No. (Plant Elecr. Only)
f,�'1 G�5 �T�C c,400 $2�
Mailing Address (Conhacfor or GiwnerPerForming Insiallafion) _ __ � _ � �,. ,
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6w��r Pe ' Ilafio Phone No.
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY