P - 82096� REQUEST FOR ELECTRICAL iNSPECTION °'E
� � � � (� � [ Minnesota State Board of Electricity
� V O J 1821 University Ave., Rm. S-128, St. Paul, MN 55104 �'
Phone(612)642-0800 "�'
Home Duplex Apt. Bldg. Other: New Addn
Commercial Indushial Farm mod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
er Ronge Elec. Heat Temp. Service
"X" above t e work covered by this request. Enier remarks in ihis space and on the back of the whiie copy on! . \
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Calculate Inspection Fee - This lnspection Request will not be accepted wiihout the correct fee: S��
Other Fee # Service Entrance Size Fee # Circuits/F ers
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above l OQ Amps
Transformer/Generator INSPECTOR'S USE ONLY TOT/��
Sign/Oudine Ltg. Xfmr. �✓' 6�
Alarm/Remote Conhol
Swimming Pool
I hereb certi that I ins the elecKical insfallation dexribed herein on ihe dafes sfated
Irrigation Boom RougMn DMe
Special Insp
Firwl Da
Investigative ee
THIS INSTALLATION MAY BE ORDERED DIS __ECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 months from validation date printed in this box.
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PLEASE PRINT OR TYPE
Request Date Rough�in inspection required? ❑ Yes o Inspection Other Than Rough-In: ❑ Ready Now ill Call
� Q �� O (You must call the inspector when ready) Dofe Ready:
I, icensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Addreu �Sheet, Box, or Route No.) City Zip Code
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5'on No. Township Name or No. Range No. ire No. C
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OccupanT L,� a^ � Phone No.
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Power Supplier Addre ` 1
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(Conhacror or Owrier Pedorming Installation) . � �
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re �Conhacfo r Owner rm� I 1R Phone No.
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/96 STATE BOARO COPY - SEE INSTqUCT10NS ON BACK OF YELLOW COPY