P - 84717REGIUEST FOR ELECTRICAL INSPECTION -
�i �(� ,.� 4 9 7 Minnesota State Board of Electncity
`f 1821 Universiiy Ave., Rm. S-128, St. Paul, MN 55104
� Phone (612) 642-0800
Home Duolex Aot. Blda. Other: � n•�� New Addn
Commercial Industrial Farm (/f I� �/ TG� (r.._. Remod Re ir
Air Cond. Htg. Equip. Water Hh. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by is r uesi. Ente remarks in this sp e and on Fhe back of fhe whife copy only.
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Calculafe Inspection Fee - This Inspection Requesf will not be accepted wifhout the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Lig./Trar`fic $ig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL _
Sign/Oudine Ltg. Xfmr. � Q�(/
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ed the elechical installation described herein on the dates slafed
Irrigation Boo Roughan pafe
Special Ins
Final p� �
Investigative Fee �— 2� P
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months bom validafion date printed in this box.
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* � 4 5 9 4 9 7 �' '"' PLEASE PRINT OR TYPE
Requesf Dafe Rough-in inspeclion required? ❑ Yes o Inspeclion Other Than RougMn: ❑ Reody Now
7��� �� �You musf call the inspector when ready� Date Ready:
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I, �licensed confractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sheet, Box, or Route No.� Ci�, �� Z�P C� �
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Seclion No. Township Name or No. Range No. Fire No. CounN
Occupant
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Power Sundier
Elechical Conhac�or (Company Name)
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Moiling Addreu (Conhactor or Owner Perfi
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AWhwized Signoture (Conhodor or Owner
Phone . � `� ��
Call �
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Conhacfor License No. I Masfer Lic No. (Planf Elect. C
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Phone No.
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INSTRUCTIONS ON BACK OF YELLOW COPY