P - 83757REQUEST FOR ELECTRICAL INSPECTION
5���e O 4 o Minnesota State Board of Electricity
0 1821 University Ave., Rm. S-128, St. Paul, MN 55104
_ + Phone (612) 642-0800 `'�'
Home
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Commercial Industrial Farm emod ' Ke
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enier remarks in this space and on the back of the white copJ' 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
Mobile Home Park Stall 0 to 200 Amps 3 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Ar
Transformer/Generator INSPECTOR'S USE ONLY TO���
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d ��iti � ��GGa� �C� � �
i described herein on }he dates stated
Dafe
Fee
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimmina Pool
fhatl
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Investigative Fee ��� '—"'-- -r ��
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This request void 1 S months from validaticn date printed in this box.
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* � 5 0 3 8 4 � l+ * pLEASE PRINT OR TYPE
Request Date Rough-in inspection required? ❑ Yes No Inspection Other Than Rough-In: Ready Now ❑ Will Call
��. ��. ��`� � (You must call the inspector when ready) Date Ready: � e�.� ,. C� >
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I, � licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sheet, Box, or Roufe No.� City , / Zip Code
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Section No. Township Name or No. Range No. Fire No. County
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Occupant � Phone No.
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Power Supplier Address
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Electrical Coniractor (Company Name) Conhactor License No.
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Mailing Address (Conkactor or Owner Perfoiming Installation)
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Authorized SignaMe �Conhactor or Owner Performing Installafion�
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Master Lic.
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Only)