P - 84300.'442-332 v�
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
Commercial Industrial Farm Remod
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy
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Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps i
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Outline Ltg. Xfmr. / ,S�
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ecfed the elechical installafion described herein on the dates sfated
Ir�i9ation Boom Rough-In pa�
inai I Date j 2/ Q�
Investigative Fee " ' � _�_ � �
_THIS INSTALLA710N MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS. _
OFFICE USE ONLY This requesf void 18 monihs from validation date printed in ihis box.
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* � 4 4 2 3 3 2 3* PLEASE PRINT OR TYPE���
Request Dq���� Rou h-in ins tion r uired?
/� g pec eq ❑ Yes No Inspecfion Ofher Than Rough-In: eady Now � Will Call
(( � (You musf call the inspecfor when readyJ Dafe Ready:
I, �icensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Street, Box, or Route No.) City Zip Code
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Section No. Township Name or No. Range No. Fire No. County
Occupant
STl ��
Power Supplier
n Electric. Inc. C�100808
(Conhacror or Owner Performing Insfallafion)
Phone No.
c��i_
Conhar_for License No. I Masfer Lic. No.
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BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY