P - 83380' REQUEST FOR ELECTRICAL INSPECTION ��°'E�
7,� /� ��� C (� Minnesota State Board of Electricity �
�,. �� U �-u1 1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800 '��
Home Duplex Apt. Bldg. Other: �� , New Addn
Commercial Industriol Farm , Remod Re air
Air Cond. Htg. Equip. Wofer 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 the whiie copy only.
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Calculate Inspecfion 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
$treet Ltg./Traffic $ig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTA�'�O
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
I hereb certi that 1 ins the electrical installation dexribed herein on fhe dates sfnfed
Irrigation Boom RougMn D
Special Inspe _ "
Final
Investigative /
THIS INSTALLATION MdY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 M THS.
OFFICE USE ONIY This request void 18 monfhs from volidafion date prinfed in this box.
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PLEASE PRINT OR TYPE
Request Dafe Rou h-in ins ecfion re uired? �s
g p q ❑ No Inspection Other Than RougMn: ❑ Ready No ill Ca�l
//�/� i�8 (You must call fhe inspector when ready� Dafe Ready:
I, �'licensed contractor ❑ owner hereby request inspection of the above elechical work at:
Job Address (Sheet, Box, or Roufe No.� City Zip Code
G l �� '� r
Secfion No. Township Name or No. Range No. Fire No. C nty
3o a
Occ nt Phone No.
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Power Supplier _ � ress
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Elechical Con}racfor (Company Name) Conh tor License No. Master Lic. No. (Planf Elecl. Only�
1 +r , e. t
Mai ing Address �CoMractor or Owner Performing Insfallafion) � .
� %�: ✓� �7 � L
Aufhorize Si ture Conhacror or Owner Performing Inst la ,) Phone No.
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EB-000 A-1 1 8/ STATE BOARD COPY - SEE INSTHUCTIONS ON BACK OF YEILOW COPY