P - 80997► REGIUEST FOR ELECTRICAL INSPECTION _
7/'�) � ip �/� � Minnesota State Board of Electricity
�� `�t �� 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 air
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 ihis spoce and on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Request will not be ac ed without ►he correct fee:
Other Fee # Service Entranc Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall -t 200 Amps 0 to 100 Amps
Sireet Ltg./Traffic Sig. Akiove 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR�s use oN�v TOTAL�b ��.p
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ted the electrical installation described herein on the dates stated
Irri9ation Boom RougMn Dare
Special Inspec
Final Date �_ ZO ^ S�;
lnvestigative 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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LEASE PRINT OR TYPE
Requesf Da Rough-in inspection required2 ❑ Yes No Inspeclion O�er Than RougMn: Ready Now ❑ Will Call
� � �You musf call the inspecfor when ready) Dafa Ready:
I, licensed contractor ❑ owner hereby request inspection of the above elechical work pt:
Job ddress �Sheef, , or Roufe No. City A Zip Cod
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Section No. Township Name or No. Range No. Fire No. County �
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o Supplier Address
Elechical ContraMor ,Company Name� Conhacror License No. Master Lic. No. �Plant Elecf. Only)
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Maili�Addrgs�Conhactor w Owner Performing InstaAation� /'}� � �/'�
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Au ed Signature (Conhacror or Owner Performing Instailafion� ( � v Phone No.
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0 1 A-11 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY