P - 82282�� RE(�UEST FOR ELECTRICAL INSPECTION -_�
7`� �- 2 2 4� 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 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 requesi. 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 withovt the correct fee:
Other Fee # Service Entrance S' e Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 90 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTA�
Sign/Outline Ltg. Xfmr. � i'S�
Alarm/Remote Confrol
$wimming Pool
I hereb certi that I ins ted the eleckical inslvllafion described herein on the dafes stated
Irrigation B Rough-I� Dafe
Speciallnspecti .r
Final D
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 monlhs kom validation date printed in this box.
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PLEASE PRINT OR TYPE
R uest Rou h-in ins ecfion re uired$ ❑ Yes Ins
�j g p q �.�jQ, pection Other Than Rough-In: �3eady Now � Will Call
/ `�' j% O (You musf call the inspeclor when ready� Date Ready:
I, �ensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sfreef, Box, or Roufe No.� City • Zip Code
� `�/ ��/��� ,�ort � ,
Secfion No. Township Name or No. Range No. Fire No. County
o���� /�r,� • c7 � e�o� No.
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Power Supplier Addreu
V
Eleclrical Conhacfor (Company Name) Conhactor License No. Masler Lic. No. (Plant Elecf. Only)
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Mailing Address (Contractor er Performing Insfallafion)
✓� 3 � �,� GtJ .c`� L /�l/�-�
Aut ' nature (Conhacror r Perfor ' nsmllafion� Phone No.
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E 1- 96 STATE BO INSTRUCTIONS ON BACK OF YELLOW COPY