P - 83807REQUEST FOR ELECTRICAL INSPECTION
5'j ('°j ����1 � Minnesota State Board of Electricity
1�J - 1 1821 University Ave., Rm. S-128, St. Paul, MN 55104
� Phone(612)642-0800
Home Duplex Apt. Bldg. Other: New
Commercial Industrial Farm � Remod
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
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Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amp:
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Outline Ltg. Xfmr.
Aiarm/Remote Control
Swimming Pool
I he
Irriqation Boom R,,,
thaf I inspected the electrical installation
Dafe
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Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED VGITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 1 8 months from validation dafe prinfed in this box.
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Request, ate Rou h-in ins ection r uired?
����/ -„-^ g p eq ❑ Yes No Inspection Other Than Rough-In: ❑ Ready Now Will Call
� I / (You must call fhe inspecfor when ready) Date Ready:
I, �licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Street, Box, or Roufe No.) City Zip Code
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Secfion No. Township Name or No. Range No. Fire No. Co ty
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Occu f Phone No.
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Electrical Contracfor (Company Name)
BI.AINE HTG. A/C ELECT., IN�;
Mailing Address Ir�l[ation�
55304
or O�nt Performing IlRtallafion)
Conhacfor License No. Master Lic. No.
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No.
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