P - 80405REGIUEST FOR ELECTRICAL INSPECTION
7�;J '�t = 0 2 3� Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
` Phone(612)642-0800 "�'
Home Duplex Apt. Bld . Other: New Addn
Commercial Industrial Farm Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. En►er remarks in ihis space and on the back of the white copy only.
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Calculafe Inspection Fee - This Inspection Request will not be accepted withoui ihe correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stal► 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR�s usE oN�v /r� TOTAL
Sign/Outline Ltg. Xfmr. �j�,,.e� �yv.-ex s�'� ���
Alarm/Remote Conhol
Swimming Pool
I here certi that I ins ihe elechical installafion deuribed herein on the dates stated
Iffigation gOOM� RougMn � �a
Special Inspection ��
Final Dafe�
Investigative Fee �"'�— ' '
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months 6om validation date printed in this box.
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PLEASE PRINT OR TYPE
Requesf Dafe Rou h-in ins hon r uired$ �es
9 p� � eq ❑ No Inspecfion OFher Than Rouglfln: ❑ Ready Now 0 Will Call
�,�'p�,��'�,� �You musf call the inspector when ready) Date Ready: �
I, �licensed contractor ❑ owner hereby request inspection of the above elecfrical work at:
Job Address (Sheef, Box, or Route No.) C'�w �:_ r�_�_
No. I Township Name or No. � � Range No. Fire No.
I Occupanf
Conhacfor (Company
Mailing Address (Confmctor or Owner PerF
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Au�lprized Signatyre �Confmctor o� Owner
� Phone No.
„� ��Sl� �\"1�
Conhactor License No. I Master Lic. No.
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— N� �-�� �,p�� C`cv�
dion� � W Phone No.
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- SEE 1 STRUCTIONS ON BACK OF YELLOW COPY __
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