P - 82496.% ��I�II II�II IIIII �IIII IIIII IIII� IIIII (II�I IIII IIII
*03962859*
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board ot 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 Repair
Air Cond. Htg. Equip. Water Htr. oad Mgmt. Other:
Dryer Range Elec. Heat emp. Service
"X" above the work covered by this request Enter remaiks in this space and on the back ot the white copy onty.
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Calculate Inspection Fee - This Inspection Requesi will not be accepted wiihout the Carect 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 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOT'A'Lr� , 5�
Sign/Outline Ltg. Xfmr. "LlJ
Alarm/Remote Control
Swimming Pool I hereby certify that I inspected the electrical installation described herein on the dates stated
Irrigation Boo Rough-In �ate
Special Insp * t°`
Final Dat
Investigative Fee ,� '
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
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� � OFFICE USE ONLY This request 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 ❑ No Inspection Other Than Rough-In: ❑ Ready Now Will Call
1� � p� 3/ � (You must call the inspector when ready) Date Ready:
I, �licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Street, Box, or Route No.) City Zip Code
31 l �(71e,lod� 'Dr � �e. F'c-� � le.
Section No. Township Name or No. Range No. Fire No. County
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Occupant Phone No.
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Power Supplier Address
Electrical Contractor (Company Name) Contractor License No. Master Lic. No. (Plant Elect. Ony)
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Mailing Address (Contractor or Owner Performing Installation)
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Authorized Signature (Cont ctor or Owner Performing Installation) Phone No.
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EB-00001A-11 8/95 STA E BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY