P - 84517REQUEST FOR ELECTRICAL INSPECTION -�.
�i V��= 7 5 5 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 I dustrial Farm Remod Re ir
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this reques►. 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 f 0 to 100 Amps ��
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR's usE ON�v TOTAL
Sign/Oudine Ltg. Xfmr. ' �
Alarm/Remote Control
Swimming Pool
I hereb certi Ihat I ins ted fhe elechical installation described herein on the dafes sfated�
Irrigation Boom Rough-In Dar�
$pecial Inspection
Finel �. pa�
Investigative Fe A�j 6 —��^� (�
THIS INSTALLA A ORDERED DiSC NECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 months 6om validation da/e prinfed in this box.
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Request Date Rouglrin inspecfion required2 ❑ Yes
'���� ❑ No Inspecfion O�er Than RougMn: Ready Now � Will Call
�You musf call fhe inspecfor when ready) Dafe Ready:
I, �licensed contractor ❑ owner hereby request inspection of the above elecfrical work at:
Job Address �Sh Box, or Route No.) City� Zip ody,
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Secfion No. Township Name or No. Range No. Fire No. County ,
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Phone No. l
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Conhactor �Company Name) Confractor License No. Master Lic. No. (Plant Elect C
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uldress (Conhy�tor or Owner e r ' Insfallafion) , � �� , �� � _ _
or