P - 83479REQUEST FOR ELECTRICAL INSPECTION -� w�,
C� J G7 � 9 4 7 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
Commercial Industrial Farm Remod Re air
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 ihe back of ihe white copy only.
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Calculaie 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
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR•s use oN�r TOTAL .�
Sign/Outline Ltg. Xfmr. �
Alarm/Remote Control �
Swimming Pool
I hereb certi fhaf I ins fed ihe elechical insfallafion described herein �on the dafes sfated
Irrigation Boom; " RougMn Dare
Special Inspection
Investigative Fee F�oal � ,_�__ Do ,Z
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
IIIOI II III I� III II III II I OFFICE USE ONLY This requesf void 18 months from validation date printed in this box.
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PLEASE PRINT OR TYPE
Requesf Da}e � Rough-in inspection required$ ❑ Yes �o Ins ection Other Than Rou h-In: � ad Now �
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� (You musf call fhe inspector when ready� Date Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job ^d�ss Skeet, Box, o� ute No.) �� /� � City I ZiP ���
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Section No. Township Name or No. ange No. Fire No. Couny �� �
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Power upplie Address �
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Elechic onhacfor (Company Nam Conhacfor License No. Masfer Lic. No. (Plant Elect. Only)
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Mailing A ress (Conhacbr or Owner Pe rming Installation) � i�� �
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Aufhori ed i�nature (Con or or Ow Performi Insfallafi Phone N��
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EB-000p1 A-1 1$/96 pTE BOARD COPY - SEE INST TIONS ON BACK OF YELLOW COPY