P - 83526REQUEST FOR ELECTRICAL INSPECTION
6 n�,� �(� �� Minnesota State Board of Electricity
,; f � 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 reque . Enter re rks 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 accepfed without the correci fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps to 100 Amps
Sfreet Ltg./Traffic $ig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTA�O
SignfOudine Lig. Xfmr.
Alarm/Remote Confrol
Swimming Pool
I here certi that I in the electriwl inslallotion described herein on the dales staled
Irrigation Boom Rougfrin Da1e
Special Inspec Z — O �
Final
Investigative Fee � ^— �"
THIS I_NSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MON S.
- OFFlCE USE ONLY This request void 18 months from validation date prinied in this box.
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PLEASE PRINT OR TYPE
Request Date Rough-in inspecfion required� Yes ❑ No Inspeclion Other Than RougMn: ❑ Ready Now Will Call
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(You must call the inspecFor when �eady� Date Ready:
I, icensed conhactor ❑ owner hereby request inspection of the above elechicai work at:
Job Address �Street, w Roure No.� Cily Zip Code
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Section No. Township Name or No. Range No. Fire No. Coun
Nv �
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Power Supplier � ^ q��
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EI Contrac�or ompany Na � Contr License No. Mas�er lic. No. (%ant Elect. Only)
��S ���� G �� �� �
Mailing AddreyS nhacro or Owner Performing Ins ation)
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A oriz Signatu �Conhactor r Ow er P ing Insfallafion �� j+; �� � Phone No. ,�/
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E 1A-11 8/96 y�7ATE BOARD COPY - SEE INSTRUC710NS ON BACK OF YELLOW COPY �_