P - 82217REGIUEST FOR ELECTRICAL INSPECTION �
8�•(`� � ry � Q � Minnesota State Board of Electricity
V 1 V ig21 University Ave., Rm. S-128, St. Paul, MN 55104
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, Phone (612)642-0800 " '
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re air
Air Cond. Htg. Equip. Woter 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 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 0 to 100 Amps
Sheet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOT
Sign/Oudine Ltg. Xfmr. �r �
Alarm/Remote Conhol
thaT I inspected the electrical installafion dexribed
Date
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Investi ative Fee
_THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OfFICE l�E OpLY This request void 18 months from validation date printed in this box.
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PLEASE PRINT OR TYPE
Request Dafe Rough-in inspecfion required$ ❑ Yes No Inspecfion Ofher Than RougMn: Ready Now ❑ Will Call
�?j �(, (You must coll fhe inspectw when ready� Date Ready:
I, �licensed c fractor ❑ owner hereby request inspection of the abave elecfrical work at:
lob Address (Sheef, Box, or Route No.) Ciy � Zip Code
Secfion No. I Township Name or No. �� I Range No.
No.
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Power Supplier ._ Address
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Elechical Conhaclor (Company Name) ContracWr License No. Master Lic. No. (Planf Elecl
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Mailing Addreu (Conhacror or Owner Perfwming lastallafion)
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Aufhorized $ignature �Co�hacfor or Owner Performing Installation) Phone No.
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1 A-11 8/ STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY