P - 82821REGIUEST FOR ELECTRICAL INSPECTION
6�/��� � O � Minnesota State Board of Electricity
�. 1821 University Ave., Rm. S-]28, St. Paul, MN 55104
j ' Phone(612)642-0800
Home Duplex Apt. Bldg. Other: New
mercial I trial Farm Remod
Air Con : Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the wo covered by this equest. Enter remarks in t is space and on the back of ihe white copy
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Calculate Inspection Fee - This Inspec►ion Request will noi be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps �
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTA�
Sign/Outline Ltg. Xfmr.
Alarm/Remote Conhol ,
Swimming Pool
I hereb certi that I ins ted the elechical installation described herein on the dates stafed
Irrigation Boom Rough-In - . Date
Special Inspectio
� Firal D G ` .L ^ Q
Invesfigafive Fee � ��
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WI HIN 18 MONTHS.
OFFICE USE ONLY This request void 18 monfhs from validation dafe printed in this box.
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PLEASE PRINT OR TYPE
R uesf Date Rough-in inspacTion required? ❑ Yes No Inspection Other Than RougMn: �teady Now [] Will Call
�� �You must call fhe inspeclor when ready) Dafe Reody:
I, �licensed contractor ❑ owner hereby request inspection of the above electrical work at:
lob Addreu (Street, x, or Route No.� Zi Code
� <<�.�. �e��T'���ce �'r l� P
Section No. Township Name or No. Ronge No. Fire No. unty� �
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:for (Company Name)
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(Conhacror or Owner P rming In
fure IC acfor or �✓ner Performina
Conhadw
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Master Lic. No. �Planf Elecf. Only)
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Pho e No.
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STATE BO/lFiD COPY - SEE INSTRUC710NS ON BACK OF YELLOW COPY