P - 82880���1-345 �
REQUEST FOR ELECTRICAL INSPECTION
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 Ac
Commercial Industrial Farm Remod e
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work c�red by this request. Enter remarks in this space and on the back of 1he white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted withouf the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator iNSPeCroR'S USE ONLY TOTAL �yy
Sign/Outline Ltg. Xfmr. 511�
Alarm/Remofe Control
Swimming Pool
I hereb certi tfw11 ins fed the elecfrical installafion described herein on Ihe dafes stated
Irrigation Boom Rough-ln /j Dare
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�THIS INSTALLATION MAY BE ORDERED DISCONNECT'ED IF NOT COMPLETED WITHIN 18 MONTHS.
_._. . OFFICE USE ONLY This requesf vad 1 B months kom validation date printed in this box.
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PLEASE PRINT OR TYPE
Request Date Rou h-in ins fion re uired? es
g pec q ❑ No Inspeclion Olher Than RougMn: ❑ Ready No Will Call
rou musi call the inspecfcr when ready� Dafe Ready:
I, �licensed contractor ❑ owner hereby request inspecfion of the above electrical work at:
Job Address (Shcef, Box, or Roufe No.) Ci1y � Zip Code
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Name or No. � Range No. � Fire No.
Occupant
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Pow r Sup lie� /) Addre;
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Elechical Conhacror (Company Name)
Mailing Address (Conhacfor or Owner Performing Insfa afion)
/
Authoriz Signatur onhactor or Owner Pe In IlaKon�
E&OOOOIA-11 8/9 ST BOARD CO
No.
Contracror License No. Master Lic. No.
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� � � � Phone No.
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E INSTRUCTIONS ON BACK OF YELLOW COPY