P - 83435REQUEST FOR ELECTRICAL INSPECTION �E
� � � ) � � � � � Minnesota State Board of Electricity
L 1821 University Ave., Rm. S-128, St. Paul, MN 55104
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Phone(612)642-0800
Home Duplex Apt. Bldg. Other: New
Commercial Industrial Farm Remod
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 the back of the white copy only.
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Calculate Inspection Fee - This Inspection Requesf will not be accepted without the correct k:e:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Pork Statl 0 to 200 Amps 0 ro 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator iNSVeCroR'S USE ONLY TOTAL
Sign/Oudine Ltg. Xfmr. .S/�
Alarm/Remote Confrol �'
Swimming Pool ' '
I-hereb certi thaf I ins ecfed the elechical insfallaf"qr('described herein on fhe dates stafed
Irrigation Boom (-] � [? : �) go„9M„ pa�
Invesfigotive Fee r�� �� - 2 G�
THIS INSTALLATION MAY BE ORDERED DISCONHECTED IF NOT COMPLETED WITHIN 18 MONTH .
_ OFFICE USE ONLY This request void 18 monfhs (rom wlidation date prinl�ed in this box.
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PLEASE PRINT OR TYPE 0
Requesf Date RougMin inspecfion required? ❑ Yes o Inspecfion Other Than Rough-In: ❑ Ready No ill Call
�/ �� 7��� (You must call the inspecfor when ready) Dafe Ready:
I,�ensed confractor ❑ owner hereby request inspection of the above electrical work at:
lob ljddress �Street, Box, or RouAe No.) Ciy Zip Code
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Section No. Township Name w No. Range No. Fire No. County
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�ccupant_ _ Phone No.
� Power Suppliey / � Address
Conkactor (Company Name) � � Conhaclor License No. Master Lic. No. (%c
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�ddress Contractor or Owner PerForming Installafion)
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d.� nature (Confracbr or Owner Perfwming InsMllution) t' Phone No.
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A-11 S/9 S7ATE BOARD COPY - SEE MISTRl1CTIONS ON BACK OF YELLOW COPY