P - 83117REQUEST FOR ELECTRICAL INSPECTION -
5 0�•� 2 0 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 Indusfrial 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 Inspeciion Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall to 00 Amps 0 to 100 Amps 0.��
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY T�L �
Sign/Oudine Ltg. Xfmr.
a
Alarm/Remote Control
Swimmin Pool
I here certi that I in ed�ed the elechiwl installalion described herein on the dales stalad
Irrigation Boom Ro�M� + �re
Special lnspecti
Final� Dore �--• �/
Investigative F O
THIS INS7ALLATION MAY BE ORDERED DISCONNECTEQ If NOT COMPLETED WITHIN 18 MONTHS.
OFF7CE l�E ONLY This reqoest void 18 months irom wlidafion dale prinAed in this bwc.
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* 0 5 0 1 2 � 2 6�R PLEASE PRINT OR TYPE
Request Date Rough-in inspection �required? ❑ Yes ❑ Rea N ill Call
❑ No Inspeclion Olher Th RougMn: dy
�� � (You must call the inspecAOr when ready) �Date Ready: g �
I, licensed contractor ❑ owner hereby request inspection of ihe obove electrical work at:
hb Address (Skeet, Box, w Route No.) Ciy Zip Code
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Secfion No. Township Name w No. Range No. Fire No. oun� �.
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Occupant Phone No. �.
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Power Suppli � Address
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Electrical Conhactor (Company Name) Contrac�or License No. Masfer Lic. No. �WaM Elecl. Only)
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Mailing Address �Conhacfor or Owner Performing Insfallafion e
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Authoriz SignaNre C r Owner P ing Iq�allafion) one No.
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$�96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY