P - 80645� REQUEST FOR ELECTRlCAL INSPECTION <,:o:,.o;;„....
7���� 0 G` � 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 Industrial Farm Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Olher:
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 onJx
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Calculate Inspection Fee - This Inspection Request will not be accepted withoui ihe correcf 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 INSPECTOR'S USE ONLY TOTAL
Sign/Outline Ltg. Xfmr. � Da
Alarm/Remote Control
Swimming Pool
I hereb ceAi fhat I ins ected fhe electrical installation described herein on the dates stated
Irrigation Boom RougMn Dafe
Special ti n �--�--�� � —�` '
Investig v F F� �OZ _� a�
THIS INSTALLATfO MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This request void 18 months from validation date printed in fhis box.
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PLEASE PRINT OR TYPE
Request Date Rough-in inspecfion required$ Yes ❑ No Inspecfion Other Than Rough-In: ❑ Ready Now ill Call
�� (You must call the inspector when ready) Date Ready:
I, �'licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sheet, Box, or Roufe No.) City Zip Code
Sect`i'n N6'�iownship Name�No. I Range No. I Fire No. f
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Occupant
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Phone No.
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il Conhactor (Company Na e) Conhactor License No. - Masfer Lia�
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Address �Confracfor or Owner Performing Insfallafion) �
/�iL` ( :1.�Q `G � ��L. /// �
or Ov� PerForming InsFallaKon) Phone I
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BOARD COPV - SEE INSTRUCTIDNS ON BACK�OF YELLOW COPY