P - 83251���-260
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800 "�'
Home Duplex Apt. Bldg. Other: New Addn
mmercial Industrial Farm Remod
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covere���'s request. Enter rem s in t�s�e and on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted wifhout ihe correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ON�Y TOT�%/� j�
Sign/Outline ltg. Xfmr. !-/V /�-/✓
Alarm/Remote Conhol
Swimming Pool
I hereb certi that I ins the elechical insfallafion described herein on ihe daTes staled
Irrigation Boom Ro„yF,�„ pare
$peciallnspect �
Final
Investigative Fee ''
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMP�ETED WITHlN 18 MONTHS.
_ OFFlCE USE ONLY This request void 18 months (rom validation date prinfed in this box.
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* 0 6 4 8 2 6 0�! � ��7 � 9
PLEASE PRINT OR TYPE
Request Datyf���'� /► Rough-in inspection required? ❑ Yes No Inspectio� O�er Than RougMn: Ready Now � Will Call
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� �You must coll the inspeclor when ready) Date Ready:
I, licensed contractor ❑ owner hereby request inspection of the above elechical work at:
Jo Address Sheet, Box, or R o.) Ci ' Zip Code
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$ecfion No. Township Name or N Ranqe No. Fire No. u ..�
Occupant Phone No.
Power Sup lie Address
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Electrical nfr r ompa e) � Co cfor License No. Master Lic. No.
C' �� GY� %'
Mailing Address �Contrador or Own Pe rming Ins 'on) ,
/ �/irl
Authoriz ig e �Co ctor or Ownsr Perfolmma Instalktiml . Phone No_ n
iv�r �
COPY - SEE
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ON BACK OF YELlA1AY COPY
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