P - 84291REQUEST FOR ELECTRICAL INSPECTION
�.'�,r J- 4 6 9 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
Remod
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Commercial Industnal Farm
Air Cond. tg. 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 the white copy 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 Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps �-{�L'
Street Ltg./Trar`fic Sig. Above 200 Amps Above 100 Amps
Transformer/Generotor INSPECTOR'S USE ONLY TOTAL;�
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
I hereb certi thaf I ins ted ihe elecfrical installafion described herein on ihe dates stafed
Irrigation Boo Rough-In Dafe
Special Inspe � Final Dafe _
Imestigative Fee ` �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 1 MONTHS.
OFFICE USE ONLY This request void 18 months from validafion dafe printed in this box.
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PLEASE PRINT OR TYPE
Request Date Rough-in inspecfion required? ❑ Yes
,+� ���' —/'j r ❑ No Inspection Ofher Than RougMn: Ready Now ❑ Will Call
� �' � (You must call the inspecfor when ready) Date Ready:
I, ❑ licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sfreet, Box, or Route No.) City , Zip Code
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Secfion No. Township Name or No. Ranpe No. Fire No. Coun
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pplier
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Conhactor �Company Name)
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�ddress (Conhacfor or O�ner PerForminq Inst�
Conhactor
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Phone No.
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�Contracfor or (iwner Pe 'rming Insfallafion) .
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OP
Master Lic. No.
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