P - 83842REQUEST FOR ELECTRICAL INSPECTION :���
5��,"� �� o G` Minnesota State Board of Electricity
U U 1821 University Ave., Rm. S-128, St. Paul, MN 55104
' Phone (612) 642-0800
Home
New
Commercial Industrial Farm rcemoa Re a��
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 ihe back of the white copy only.
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Calculaie Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 00 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TQT`gL . �
Sign/Oudine Ltg. Xfmr. f `�
Alarm/Remote Control
Swimming Pool / �7
I hereb certi that I ins ted the elechical installation descri r�n fhe i� ./
Irrigation Boom RougMn Date
$pecial Inspectio _ � �e ~ ~
Final i � ?y�
Investigative Fee ,;;� �"� -�
THIS INSTALLATION MAY BE ORDERED DISCONNE � ED IF NOT COMPLETED WITHIN 18 MONTHS.
� ' � OFFICE USE ONLY This requesf void 18 months 6om validafion dafe prinTed in fhis box.
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�K � 5 3 � 1 0 6 4�c PLEASE PRINT OR TYPE ��`�
R uest afe Rough-in inspecfion required? ❑ Yes No Inspecfion OFher Than RougMn: Ready Now ❑ Will Call
� (You must call ihe inspector when ready� .� Date Ready:
I, icensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Skeet, Box, or Route No.) Ciy Zip Code
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Secfion No. Township Name or No. Range No. Fire No. Cou
Occupant
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Power Supplier
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Elechical Conhactor (Company Name)
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Mailing A� ress (Conhacfor or Ownei
2$ �5 r, d,
Aiifhnri�rdSianah�re IConhacfor or O
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Phone No.
�I Conhactor License No. N
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.E INSTRUCTIONS ON BACK OF YELLOW COPY
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ister Lic. No. �Plant
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