P - 77733REQUEST FOR ELECTRICAL INSPECTION
� 0�� 3 6 4 Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
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Phone (612) 642-0800
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial 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 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 noi be accepted withovt the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feed rs Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Am
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
$ign/Outline Ltg. Xfmr. �/ �
Alarm/Remote.Co I
Swimming Pool
I hereb certi that I ins ted fhe elecfrical insfallation described herein on the dates stafed
Irrigation Boom Rough-In . D
Special Inspection � �7—G
Final DaTe / �, e tf
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHI • ONTHS.
. OFFICE USE OPLkY This requesf void }),B�monfhs from validafion dafe printed in this box.
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PLEASE PRINT OR TYPE
Requesf Date Rough-in inspecfion required? �.Yes ❑ No Inspection Other Than Rough-In: ❑ Ready Now Will Call
1 v 1� � Z (You musf call the inspecfor when ready� Dafe Ready:
I, ❑ licensed contractor �owner hereby request inspection of the above electrical work at:
Job Address (Sheet, Box, or Route No.� Ci Zip Code
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Secfion No. Township Name or No. Range No. Fire No. County
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Occupant Phone No.
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PowerSupplier Addres ��� /�/
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Electrical Conhactor �Company�e� � Contracfor License No. Master Lic. No. (Plant Elect. Only)
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Mailing Address (Conhactor or Oyu+�r Performing Installafion�
or Owner Performing Insfallation� � I Phone No. I
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s7a7E aoARO COPV - SEE INSTRUCTIONS ON BACK OF YELLOW COPY