P - 83228REGIUEST FOR ELECTRICAL INSPECTION
5 O�, 2 2 2 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 e air
Air Cond. Htg. Equip. Water Hh. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by t�quest. Enter remarks in this space and on th ack of �the� �whiief opy only.
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Calculate Inspecfion Fee - This Inspection Request will not be accepted without fhe correct fee:
Other Fee # Service Entrance ' e Fee # Circuits/Feeders Fee
Mobile Home Park Stall - 0 to Amps 0 to 100 Amps c�
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps �
Transformer/Generator INSPECTOR�S USE ONLY L„s ��
Sign/Oufline Lig. Xfmr. �
Alarm/Remote Control
Swimming Pool
I certi tlwt I in ected the elechiwl insmllarion described herein on �he dares sfated
Irrigation Boom RougMn oore
Special Inspection
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Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE I�E ODILY This requesf void 18 months kan validotion date prinfed in fhis box.
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* O S O L 2 2 L� i* pLEASE PRINT OR TYPE
Req t Date Rouglrin inspecfion required$ ❑ Yes o Inspection O�er Than RougMn: ❑ Ready N ill Call
� ��' (You must wll the inspecior when ready) � Dale Ready: �
I, icensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sheet, Box, o oufe No.) C�y Z�P C�
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Secfion No. Township Name or No. Range No. ' Pire No. unly ,�
Occ pant Plrone No. �
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Po�� s� �e '�31�� c� ��.-� CS�
Electrical Conncror �Company Name) � � � Confracror License No. Master lic. o. (Planf Elecf. Only)
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Moiling Address (Conhador or Owne Performing InsTallalion) � .
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uthoriz ign (Conhactor o er P� ing Insfallafion) �Ph No. .
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EB-00001 A-1 1 8/96 �7p7E gOARD COPY - SEE INSTRUCTIONS ON BACK OF VELLOW CAPY