P - 81724REQUEST FOR ELECTRICAL INSPECTION ID �
� � g � � � � � � Minnesota State Board of Electricity
182Y University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 i��:
(651) 642-0800 www.electricity.state.mn.us " '
Home Duplex Apt. Bldg. Other: �✓ n ��1��� New Addn
Commercial Industrial Farm � J O ��, (.i(.'l���ls(►-C���� Remod Repair
Air Conditioner 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 accepted wiihout the correct fee:
Other Installations Fee # Service Enhance 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 TOTA ���
$ign / Outline Ltg. Xfmr. �
Alarm/Remote Control
Swimming Pool
I hereb certi that 1 ins cted the elechical instaNation described herein on Ihe dates stated:
Irrigation Boom Rough-I� �re
Soecial InsoeaElrC] A 1 n
THIS INSTALLATION MAY BE ORDERED DtSL`ANli�TED IF NOT COMPLETED WITHIN 18 MONTHS.
� � OFFICE U8E ONLY This request void 18 months from validafion date printed in fhis box.
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� PLEASE PRINT OR TYPE
Request Date .�,. Rough-in inspecfion required? ❑ Yes ❑ No Inspecfion Other Than RougMn: ❑ Ready No ill Call
2 r2 I�G � You must caH the inspecror when ready Dote Ready:
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I,j�4icensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sheet, Box, or Roufe No.) _ City „' �� Zip Code
$ection No. Township Name or
Occupant
�ti �'F�
Power Supplier
Electrical Contracfor / Company I
F.�r- a
Mailing Address (Confractor, Con
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. Range No. Fire No. Coun
� U Cn Phone No.
Addres � �
/, Confractor License No.
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or Ownyr�rforiing Installation� / A R \ �
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(Contractor, Company or
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Masfer Lic.
SEE INSTRUCTIONS ON BACK OP YELLOW COPY