P - 84535- -= "� REQUEST FOR ELECTRICAL INSPECTION - -:.
`F �� a 2 9 6 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 Indusfrial Farm Remod Re ir
Air Cond. Htg. Equip. Water Hfr. 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.
N�-/ � I � e� T��Vac.G�
Calculate Inspection Fee - This Inspection Request will not be accepted without ihe 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 ONLY TOTAL
Sign/Outline Ltg. Xfmr. �� �Q
Alarm/Remote Control
Swimming Pool
I hereb cerfi that I ins fed fhe elecfrical insfallation described herein on the dates siated
Irri9ation Boom Rougf�ln pa�
Special Inspect'
Final p° )r @�
Investigative Fee � -� y
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This requesf void 18 months from validation date printed in this box.
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* D 4 4 L 2 9 G L* PLEASE PRINT OR TYPE
Request Dafe Rough-in inspecfion required? ❑ Yes ,�No Inspecfion Ofher Than RougMn: �Ready Now � Will Call
'� � (You musf call the inspecfor when ready) Date Ready:
I, � licensed contractor ❑ owner hereby request inspection of the above electrical work at:
1ob Address �Sheef, Box, or Route No.) City Zi Code
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Secfion No. Township Name o o. Range No. Fire No. oun
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Power S000lier
Electrical Conhactor �Company Name) Contraclor Lice
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Mailing Address ( onhacfor or Owner PerForming InstalloTion)
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Aulhorized Sipnature (�ontracbr or Owner Performina Installationl _. � -
Phone No.
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Master Lic. No. (Plant
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Phone No.