P - 84610REGtUEST FOR ELECTRICAL INSPECTION -.�
'`F �F C? � 918 Minnesota State Board of Electriciry
1821 University Ave., Rm. S-128, St. Paul, MN 55104
. � Phone (612) 642-0800
Home Duplex Apt. Bldg. Other: New Addn
ommercial Indusfrial Farm Remod Re ir
Air C� 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.
Calculote Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders
Mobile Home Park Stal► 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR's usE oN�v TOTAL
Sign/Outline Lig. Xfmr.
Alarm/Remoie Control
Swimming Pool
I hereb certi fhat I ins fed the elechical insfallation described herein on the dates sfated
Irriqafion Boom „ R�,�,�„ ��
F�
�ssa �
$pecial Inspecti
Final � Da ,`.Z � _\
Investigative Fee � � E��'
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validation date printed in this box.
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9 L 8 5 PLEASE PRINT OR TYPE
Requesf Dafe Rough-in inspection required? ❑ Yes �No Inspeclion Other Than RougMn:
��G �� (You must call the inspector when ready� Date Ready: ��/��G
I, licensed contractor ❑ owner hereby request inspection of the above elechical work ah
Job Addreu (Sheet, Box, or Route No.� City
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Secfion No. Township Name or o. Range No. Fire No. County
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Power Supplier
Elecfrical Conhacfor IComoanv Namel
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AAailing Address (Conkaclor or Owner Performiig Inslalla
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Aulnorized Sipnalure IContractor or Owner Performina In:
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Ready Now ❑ Will Call
Zip
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Phone No.
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Conhador License No.
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Master Lic. No.