P - 81466REQUEST FOR ELECTRICAL INSPECTION �
� 1� L- 5 5 5 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 air
Air Cond. Htg. Equip. Water Hh. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work overed by fhis request. Enier remarks in this space and on the back of the white copy only.
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Calculate Inspeciion Fee - This Inspection Request will not be accepted without fhe correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 fo 200 Amps � 0 to 100 Amps
Sheet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR�s use oN�Y TOTA
Sign/Oudine Ltg. Xfmr. �
Alarm/Remote Confrol
Swimming Pool
I hereb certi thaf I in the elecfical installafion described herein on the dates stated
Irrigation Boom Ro�Mo �
$pecial Inspecfion —
Finol
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WIT IN 18 MONTHS.
OFFICE USE ONLY This request void 18 months bom wlidaKon date printed in this box.
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PLEASE P�I�IT OR TYPE
Request Date Rough-in inspacfion required? Yes ❑ No Ins on Other Than Ro Mn:
�L t j} t} j� n pecli ug ❑ Ready Now ❑ Will Call
7 7 y ou musf call the inspec�or when ready) Dale Ready:
I, ❑ licensed confractor �,owner hereby request inspection of ihe above elechical work at:
lob Addreu (Sheef, Box, or Rou�e No.) City Zip Code
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Secfion No. Township Name or No. Range No. Fire No. Couny
Occupanf Phone o.
Power Supplier Address CO f t'' / Z^ Z 3 7 Q
�} P 1� / $� Fttt�v�a� C•✓Z
Elechical Contrac�or (Comppqy Name) Conhactor License No. Master Lic Nn IW�,�� Fl�e n..l..�
Address (Conh�rawner Performing
No.
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