P - 80812REQUEST FOR ELECTRICAL INSPECTION
�b���� � 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. Heaf 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
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR's use oN�v T�L �
Sign/Outline Ltg. Xfmr. '
Alarm/Remote Control
Swimming Pooi
I hereb certi that I ins the elechical installation described herein on the dates stated
Irrigation Boom go„9M„ Da /
Spec+al Inspect' � " � y
Final Date _�'
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DiSCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 monfhs f�om validafion dafe printed in this box.
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PLEASE PRINT OR TYPE
R uest Date Rou h-in ins �on r uired$ ❑ Yes
g pecl' eq ❑ No Inspection Other Than RougMn: ❑ Ready Now � Will Call
� (You must call the inspector when ready� Date Ready:
I, ❑ licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address �Street, Box, or Roufe No.) Ci�� Zip Code
�.u� �. � �1� s �
Secfion o. Township Name or No. Range No. Fire No. C
P �% �2 t - �� � P•
Powe,r 5ypplier Address � � .
N�J 1� ��l S v,
Elech� Conhacfor �Company Nome� Contraclw License No. Masier Lic. No. (Planf Elecf. Only)
�'E � El2 aAC(� �� E.�' C �� ,�--f� C
Mailing Address (Conkacfor or Owne`Performing InsTallation� �'�
3
nthorize ignature (Conhacror or er Performing Installafion� /� A Phone No.
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EB-00 -11 8/9b STATE BOARD PY - S INSTRUCTIONS ON BACK OF YELLOW COPY