P - 82640� REQUEST FOR LECTRICAL INSPECTION
'� .L J-19 5 Minnesota State ard of Electricity
1821 University ve., Rm. S-128, St. Paul, MN 55104
Phone(612) 2-0800 '�'
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 the back of fhe white copy only.
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Calculafe Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entr ce Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 �(� � 0 to 100 Amps d 5, (�
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Outline Ltg. Xfmr. �`�, r�_��- ��-�,. �jG y Gl p.�
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Alarm/Remote Confrol
Swimming Pool
I hereb certi that I ins ected the elechical installation described herein on the dafes stated
Irrigation Boom Rough-In Dor�
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THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf voio 18 months from validation date prinfed in this box.
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PLEASE PRINT OR TYPE
Request Dafe Rough-in inspection required? ❑ Yes o Ins eciion Ofher Than Rou h-In:
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6 (You mus� call thz inspector when ready) Date Ready:
I,�j licensed contractor ❑ owner hereby request inspection of the above elecfrical work at:
lob Address �Sheet, Box, or R ufe No.� C�A, � Z�P C�e
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Section No. Township Name or No. Range No. Fire No. County � �
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actor �Company Name)
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Phone No.
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Conhacfo� License No. �, '
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'���Mas Lic. No. (Plant
Perform�g Installation� � Phone
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BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY