P - 84130RE(�UEST FOR ELECTRICAL INSPECTION
5^� ��� Z C � Minnesota State Board of Electricity
J U 1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800 /
Home Duplex Apt. Bldg. Othe
Commercial Industrial Farm �
Air Cond. 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 Ih
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New
Remod
copy
Calculate Inspection Fee - This Inspection Request will noi be accepted without the correct fee:
Other Fee # Service En anc e Fee # Circuits/Feed Fee
Mobile Home Park Stall 0 200 ps "' 0 to 100 Amp
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL J
Sign/Outline Ltg. Xfmr. / . ��
Alarm/Remote Control
Swimming Pool
I hereb certi fhat I ins fed ihe elechical insfallafion described herein on the dates stated
Irri9ation Boom Rough-In � - � � D re `�' � �
Special Inspection � � ��
Final D
Investigative Fee _i"�----- �%;--"�
THIS INSTALLATION MAY BE ORDERED DISCONNEC D IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This requesf void 18 months (rom validafion dafe prinfed in }his box.
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* � 5 3 2 4 7�i 9* PLEASE PRINT OR TYPE
Requesf Dafe Rou h-in ins ection re uired2 � Yes
g p q ❑ No Inspecfion Ofher Than Rough-In: ❑ Ready Now Will Call
'� —���" (You must call the inspecfor wh n ready) Date Ready: �
I, ❑ licensed contractor �owner hereby request inspection of the above electrical work at: -
Job Addr� t, Box, Route No.) � //tl��� � �J�� Zip�� ��
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Section No. Township Name or No.
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r�
Oc � nt .
Po��ie�
Electrical Contractor (C�any Name)
Mailing Address
A-I 1
or Owner Performing Installation)
or
Conhacfor License No.
No.
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Masfer Lic. No.
Phone No.
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