P - 80990REGIUEST FOR ELECTRlCAL lNSPECTION -
5 �.4 _ 19 9 Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
• Phone (612} 642-0800
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Home Duplex Apt. Bldg. 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. 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 withouf the correct fee:
Ot[� Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park tall 0 to 200 Amps 0 ro 100 Amps
Sfreet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR•s use aav TOT�L� ��-�
Alarm/Remote Confrol
Swimming Pool
� I he cerli Tha1 I in the elechical installalion described herein on Ihe dopes s6aled
Irrigation B Rou9Mn Dare
Speciallns o
Final Dare
tnvestigotive Fee �O �Z �—�
THIS INSTALLATION MAY BE ORDERED DI�NNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE U9E ONLY This raqwsf vad 1 S months from wlidaTion date printed in this box.
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Request Date Rou fFin ins on r uired� ❑ Yes specli oug ❑ Ready Now
/' g pecli eq ❑ No In on Olher Thon R Mn: ❑ Will Call
`o �(( "�/ iYou mus� call the inspector when teady) Dale Reody:
I, �licensed conhactor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Street, Box, or Route No.) Ciy Zip Code
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Section No. Township Name or No. Ranpe No. Fire No. CounH
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Power Supplier
Eleclrical Conhactor (Company Nar
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Mailing Address (Conhacror or Ovn
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Authwized ' relConkacfo :or
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BOARD COPY - SEE WSTRUCTIONS ON BACK OF YELLOW COPY