P - 83915REQUEST FOR ELECTRICAL INSPECTION �..
5 4.4 �---`t J� Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �
Phone (612) 642-0800
ome Duplex Apt. Bldg. Other. �y,�� / New Addn
Commercial Indushial Farm /-' /2 �Fjr 4 G�-•r�— Remod Re ir
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 Inspec►ion Fee - This Inspection Request will noi 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
Tronsformer/Generator INSPECTOR'S USE ONLY TOT�� �
Sign/Outline Ltg. Xfmr.
Alarm/Remote Confrol %�j�
Swimming Pool � J
I hereb certi that I ins ted the elechical installation described herein on the dates stated
Irriqation Boom Q�„�I,a� Date
.,r,,....... .....r..,....� . - Final � ,j �� �. I Date/ ! �✓ � [
Investigative Fe � �G��_ 7
THIS INSTALLATION MAY BE ORDERED DISCdNNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 monfhs from validaficn date printed in this box.
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Requ 1 Date �� Rough-in inspecfion required? ❑ Yes o Inspection Other Than Rough-In: eady Now ❑ Will Call
�� �� � (You must call the inspecfor when ready) Date Ready:
I, icensed conhactor ❑ owner hereby request inspection of the above electrical work at:
Job Ad ress Sfreef, Box, or Route o.) City ` Zip Code
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Secfion No. Township Name or No. Range No. Fire No. ounty !
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Occupant
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r or O�yner Performing
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Phone No.
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Con dor Lice se N Master Lic. No. (Planf E
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