P - 80318, REQUEST FOR ELECTRICAL INSPECTION —
(� � p � � � /� � (� � Minnesota State Board of Electricity �
L� Q `'f � 1821 Universiry Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 ��`
(651) 642-0800 www.electricity.state.mn.us
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Repair
Air Conditioner Hfg. Equip. Water Hfr. 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 Reque�wil�l not be accep d`it out the cor er ct�ee� ��e
Other Insfallations Fee # Service Enirance Size Fee # Circuifs / Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 6f • 0 to 100 Amps
Street Ltg. / Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL M
Sign / Outline Ltg. Xfmr. �/�.,Gi�.. � S v 3d� l"
Alarm/Remote Control
Swimming P
I hereb certi that I ins ted the elechical installation described herein on the dates stated:
Irrigation Boom Rough-In Date
Special Inspection -
Final - Da
Investigative Fee "
THIS INSTALLATION MAY BE ORDERED DIS ONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE U8E ONLY This requesf void 18 months 6om validation date printed in this box.
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PLEASE PRINT OR TYPE
Requesf Dafe Rough-in inspection required� ❑ Yes �lo Inspecfion Ofher Than Rough-In: �eady Now ❑ Will Call
3�. � g� V� You must call fhe inspecfor when ready Oote Ready:
I, icensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address (Street, Box, or Route No.) Ciy .Zip Code �
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Secfion No. Township Name.or No. Range No. Fire No. unty
. µ,
Occupani Phone No.
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Power Supplier � r� � � � Address
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Elechical Con}ractor / Company Name Conkacfor License No. Master Lic. No. (Planf Elecf. Only�
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Mailing A ress (Confracfor, Company or Owner Performing Installation) �
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Auth ized Si a (C acfor, Co y or r rmin In II i Phone Number .
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EB- 1A- 5/1999 STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY