P - 80332�-�92-553 �
REQUEST FOR ELECTRICAL INSPECTION �'�°_
Minnesota State Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993
(651) 642-0800 www.electricity.state.mn.us "ffi'
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Repair
Air Conditioner Htg. Equip. Water Hfr. Load Mgmf. Ofher:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on ►he back of the white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted without the correci fee:
Other Installations 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 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign / Outline Ltg. Xfmr. ��
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ected the electrical inslallation described herein on the dates stafed:
Irrigation Boom Rouqh-In Date
Final / I Uate]_[�. ��.0�� �
Investigative Fee ( — -/
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 fhis box.
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PLEASE PRINT OR TYPE
Requesf Dafe Rough-in inspecfion requiredZ ❑ Yes ❑ No Inspecfion Ofher Than RoughJn: Ready Now � Will Call
��'2 ^'' � (� Q You musf call the inspecfor when ready Dafe Ready:
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I, licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address �Sfreet, Box, or Roufe No.) City Zip Code
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Secfion No. Township Name or No. Range No. Fire No. Cou
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Occupant •
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Po er Supplier Ad
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Electrical onhactor / Company Name
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Mailing Address (Contractor, Company or Owner Performin$ In:
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Signafure (Confmctor, Company or Owner
Phone No.
ConNacfor License No. Masfer Lic.
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2 5/1999 STATE BOARD COPY � SEE INSTRIICTIONS ON HACK OF VELLOW COPV