P - 82101���°194 �
RE(�UEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-080Q,
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Home Duplex Apt. Bldg. Other: �� ��r New
Commercial Industrial Farm � �� °---
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" pbove work covered y this requ st. Enter remarks in this space and on
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Calculate Inspeciion Fee - This Inspection Request will rot be accepted without fhe correct fee:
Other Fee #$ervice Entrance e Fee # Circuits/Feeders Fee
Mobile Home Park Stall to 00 Amps 0 fo 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S u5�`� �J Y/ TOTA
Sign/Outline Ltg. Xfmr. i� p�l .S�
Alarm/Remote Control i
Swimming Pool
I hereb certi that I in the eleclrical installafion desc�ibed herein on �e dates staled
Irrigation Boom RougMn pare
Special Inspecti /
Final Da1e `
Investigative Fee (�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validation date printed in this box.
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PLEASE PRINT OR TYPE
Request Date Rough-in inspeclion required? ❑ Yes
❑ No Inspection O�er Than RougMn: ❑ Ready Now ❑ Will Call
�� � Q �You musf call the inspecfor when ready) Dafe Ready:
1, ❑ licensed contractor �owner hereby request inspection of the above electrical work at:
Job Address (Sheef, Box, or Route No.) Cily Zip Code
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Secfion No. Township Name orDlq. Rang�� fire No. C ly � �
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OccupanT � ' �? Phone No.
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Power Supplier Addres
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Electrical Contractor (Compa e) Conhaclor License No. Master Lic. No. (%ant Elecf. Only)
Mailing Address (Conhacfor or O�wnl1 Performing Installafion�
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OP YELLOW COPY