P - 84683REQUEST FOR ELECTRICAL INSPECTION ��..
�fr'�s J- 519 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 Addn
ommercial Indushial Farm emod Re ir
ir Con tg. Equip. Water Hfr. 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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Colculate Inspection Fee - This Inspection Request will noi be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stal! 0 to 200 Amps 0 to 100 Amps
$freet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Oudine Ltg. Xfmr.
Alarm/Remote Confrol
Swimminq Pool
I hereby certi(y thaf I inspecled fhe elech�ical insfallation dexribed herein on fhe dates slafed
Rough-In pa�e
Investigative Fee - � � ��'� ���_. � � � �
THIS INSTALLATION MAY BE ORDERED DISCO D IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This request void 18 monfhs from validation date printed in this box.
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* � 4 6 5 5 L 9 7* PLEASE PRINT OR TYPE �
Request Date Rough-in inspection required? ❑ Yes �14o InspecFion Other Than Rough-In: ❑ Ready Now ill Call
�� �,� —� � (You must call the inspector when ready) Date Ready:
I, icensed confractor ❑ owner hereby request inspection of the above electrical work at:
lob Addreu (Sheef, Box, or Route No.) City _ Zip Code
Seclion No. � Township Name or
Occupanf
�.ounry �^ E
! l, V�%x�
Phone No.
Power Supplier � ' dress
BWNE HTC3. A/C ELECT ., �
Eleclriml Conhaclor ( O Conhacfor License No. Masfer Lic. No. (Plant Elecf. Only�
, MN 55?^�' �
Mailing Addreu �CQnhaclw or O�ner Performirg Installafion)
; msrananon� ' { � J / !� % I Ph_ne No_
1 �/
ON BACK OF YELLOW COPY