P - 80640� i 11�111 IIIII IIIII IIIII IIIII IIIII IIIII IIIII IIII IIII
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REQUEST FOR ELECTRICAL INSPECTION ��
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 Repair
Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter rks in this space and on ihe back of the white copy only.
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Calculate Inspection Fee - This Inspection Request will not 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�L }J�
Sign/Outline Ltg. Xfmr. V(/�
Alarm/Remote Control
Swimming Pool I hereby certify that I inspected the electrical installation described herein on the dates stated
Irrigation Boom Rough-In oate
Special Ins c � n
Investigative Fee Finai �ac _ 2_�/
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.
396-234 � ��-�j
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PLEASE PRINT OR TYPE
Re ue t D� Rough-in inspection required? ❑ Yes o Inspection Other Than Rough-I � ady Now ❑ Will Call
(You must call the inspector when ready) Date Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Ad rq��reet, Bo �Rou` ;eDNo.� / )/ City �L /� Zip e ��
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Section No. Township Name or No. Range No. Fire No. Gounty
u � � Phone ya�� — � �
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Power Supplier Address
Ele 'cal C�ra�� ompany�s) _ Contrac r License No. Master Lic. No. (Piant Elect. Only)
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Mai � ��dress (Co ra tor or Own�r �rto� Ins Ilat� ) � � � � �����
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Author'zed ignat re (C �ractor or Owner Pe orming Installation) P���� I�„ p� ^
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EB-OOOOtA-11 8/95 STATE BOARD COPY - SEE ��. U- IONS ON BACK OF YELLOW COPY