P - 82806RE(�UEST FOR ELECTRICAL INSPECTION
, V�0 - 5 8 5� Minnesota State Board of Electricity
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1821 University Ave., Rm. S-128, St. Paul, MN 55104 �
` Phone (612) 642-0800 `' '
Home Duplex Apt. Bldg. Other: New Addn
ommercial ndustrial 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. Enier remarks in ihis space and on the back of the white copy only.
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Calculaie Inspection Fee - This Inspection Request will not be accepted withouf 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 Amps '
Transformer/Generator INSPECTOR'S USE ONLY TOTAL,�
Sign/Outline Ltg. Xfmr. l !
Alarm/Remote Control
Swimming Pool
I hereb certi that I in ted the electrical insfallation described herein on the dares stated
Iffi9ati0� BOO Rougf�ln Date
Special Inspe
Firml Date
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONN TED IF NOT COMPLETED WITHIN 1S MONTHS.
_... ._. .. .._ .. _. _. _. ._ _.. OFFICE USE ONLY This request void 18 months from validation date prinred in this box.
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PLEASE PRINT OR TYPE
Requesf Dafe Rou h-in ins ecfion r uired$ ❑ Yes
`�� g p eq ❑ No Inspecfion Olher Than Rough-In: Ready Now 0 Will Coll .
�You must call the inspecior when ready) Date Ready:
I, censed contractor ❑ owner hereby request inspection of the obove elecfrical work at:
Job dress (Sheet, Box or Roufe No.) � . Ciry Zip Code
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Secfion No. Township Name or No. Range No. Fire No. County
Occupanf phone No. �
I' �rn `��� f �- 9
Power Supplier ^ `� � reu
r�
Elechical Conhncror (Company Name) Cgq�racpr License No_ � Master Lic. No. (NaM Elect. Only)
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�$� STATE D OPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY