P - 82945RE(�UEST FOR ELECTRICAL INSPECTION
�'�t�� — 5 2 5� Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
� Phone (612) 642-0800 '�'
ome Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re air
ir Cond,d Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Requesf 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./Tra(fic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator MSPECTOR'S USE ONLY TOTA� ��
Sign/Outline Ltg. Xfmr. �
AlarmfRemote Control
Swimming Pool
I hereb certi that I ins the eleclricnl installation described herein on the dates stated
Irrigation Boom RougMn Date
Specia( Inspecti _ ►
Finol � Da�� /
Investigative Fee � `
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
. OFFICE I1SE ONLY This request void 18 months from validation date printed in this box_
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PLEASE PRINT OR TYPE
Requesf fe Rou h-in ins ion r uired?
g ped� eq ❑ Yes o Inspecfion Olher Than Rough-In: Ready Now 0 Will Call
���� 8 �You must call the inspecfor when ready) Date Ready:
I, 'censed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address �Sheet, Box, or Route No.) � ` � C�y ` Z��� �
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Seclion No. Township Name or No. Range No. Fire No. County
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Occupant Phone No.
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Po er S p�r � � ddress �� �
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EI ' al C_ onhac r(Company Name) ���Y � Conkacror Li� No. Master Lic. No. (Plan . Only�
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Mailing Address (Conkacfor or Owner PerForming InsMllafion) ���� �
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A h z Si hire �C hactor ner P rfor ' g Ins afion) Phone No.
E 1A-11 8/96 �'
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ATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY