P - 81209REQUEST FOR ELECTRICAL INSPECTION
��� T 3 51 Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800 ' �
Home Duplex Apt. Bldg. Other: Addn
Commercial Indusfrial Farm Remod Re air
Air Cond. Htg. 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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Calculate Inspection Fee - This Inspection Request will not be accepied wifhout the correcf fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Sfreet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generato� INSPECTOR�S USE ONLY TOTAL j p
Sign/Outline Ltg. Xfmr.
3�� �o�
Alarm/Remote Control
Swimming Pool
I hereb cerTi that I ins the elechiwl insMllafion described herein on the dales sMted
Irrigation Boom R��,.�„ r-� pare ____ � e
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
� �� OFFICE USE ONLY This request void 18 monfhs from validation date printed in this box.
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PLEASE PRINT OR TYPE
Requesf Dafe Rough-in inspeclion required? �Yes ❑ No Inspech:on Other Thon RougMn: ❑ Ready Now � Will Call
�' �, q� q 9 (You musf call fhe inspecfw when ready� Dofe Ready:
I, ❑ licensed conhactor ❑ owner hereby request inspection of the above electrical work at:
lob Ad�ress (Street, Box, or Route No.) Ci Zi Code
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iecfion No. Township Name or No. Range No. Fi�e No. County
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Eleth�ical Conhactor �Coropuny Nume�
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Mailing Address �Contrac�or w Owner PerForming lnstollofion)
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4ufhorized Signature (ConkacFOr o�er Per(ormi InsfallaKOn) I`/ �) V�,j �J J Phone No.
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY
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Phone No.
S'�i- 3�1�1
Conhactor License No. Moster Lic. No. (Plant Elecf. Onh
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