P - 80972REQUEST FOR ELECTRlCAL INSPECTION
�� g���� � 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 Indushial Farm
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
X" bove the work covere by this request. Enter remarks in this space ond on the back of the whif
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Calculate inspection Fee - Tf�is Inspection Request will noi be accepfed without the corcecr fee:
Other Fee # Service Entrance Size Fee # Circuits/Feedi
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100
Transformer/Generator INSPECTOR'S USE ONLY TC
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
copy only.
0
I hereb certi that I ins ted the eleclrical installation descri6ed herein on the dates stoted
Irriqotion Boom R�„��„ ��
Fee
I THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
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_ OFFICE USE ONLY This requesi void 18 months from validation date printed in this box.
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PLEASE PRlNT OR TYPE
Requ=sl �aie � Rou h-in ins cfion r uired?
g pe eq ❑ Yes No Inspection Olher Than Rough-In: ❑ Ready Now Wilt Call
�You must call Ihe inspector when reody) Date Ready:
I, �licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Addr ss heet, Box, or Rou No.) Ciy Zip Code
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Section No. Township Name or No. Ranpe No. Fire No. C oN� �
on / C
:r Sup ier
// �� i
rical Contmcior (Company
Mailing Address (Conhac(�
1�o�.sun�
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� Phone No. � -
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� 4 8� Address � oSra c,
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Name Contracror License No. Master Lic. No. �Plant Elecf. Only)
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Owner PerForming Ins Ilafion)
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�0 �(�-I Q, �
�r or ner P horm' stallation) Phone No.
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STATE BOARD CO Y- SEE INSTHUCTIONS ON BACK OF YELLOW COPY