P - 84171I r4�7-473 �
Commercial
Air Cond.
Dryer
"X" above the work
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
Apt. Bldg. Other: New
Farm Remo�
Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
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 Fee
Mobile Home Park Stall 0 to 200 Amps to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Outline Ltg. Xfmr. G` 9D4y� .j �'�
Alarm/Remote Control ��f� �� �i`��
Swimming Pool
I hereb certi that I ins ted the elechical installation described herein on the dates stated
Irri9ation Boom Rough-In pa�
Special Inspection, " � � �—
Final
Investigative Fee �°} G �'
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS_
OFFICE USE ONLY This requesf void 18 months from validation dafe prinfecl in this box.
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* 0 4 9� 4 7 3 9�k PLEASE PRINT OR TYPE �:�d `Y" �
Request Date Rough-in inspecfion required? �s ❑ No Inspxtion Ofher Than Rough-In: ❑ Ready Noy��Nill Call
�"�"� � 9 (You must call fhe inspector when ready) Date Ready:
I, , 'censed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Streef, Box, or Route o.� C� P
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Section No. Township Name or No. Range No. Fire No. Couny
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Power Supplier Address �
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Electrical ontractor (Company Name) � Conhacfor License No. Masfer Lic. No. (Planf Elect. Only�
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4lailin ddress (Confracfor or Owner Performing Insfallation)
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4ufhorized Signat (Confractor o ner Performing Installation) � O��� Phone No. /,
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3-0 -1 1/96 ST E BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY