P - 82304REQUEST FOR ELECTRICAL INSPECTION
U�� p�� 4�� � Minnesota State Board of Electricity �
O 1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993 ��`
_ (651) 642-0800 www.electricity.state.mn.us
Home Duplex Apt. Bldg. Other: New Addn
Commercial Indusfrial Farm Remod Repair
Air Conditioner Hfg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enier remarks in this space and on the back of ihe white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted withouf the correct fee:
Other Installations Fee # Senice Entrance $ize Fee # CircuiTs / Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Sfreet Ltg. / Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL'�O
Sign / Outline Ltg. Xfmr. �
Alarm/Remofe Control �R �°Z
Swimming Pool rO'
1 hereb certi that I ins ted the elechical installation described herein on the dates stated:
Irrigation Boo Rough-In Date
Speciallnspec ti}
Investigative Fee �_ �dr. �" �
THIS INSTALLATION MAY BE ORDERED CONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
� OFFICE USE ONLY This request void 18 monfhs from validation dafe printed in this box.
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PLEASE PRINT OR TYPE
Requesf te Rough-in inspecfion required$ ❑ Yes � Inspection Ofher Than Rough-In: y Now � Wiil Call
. You musf call }he inspecror when ready Date Ready:
I, icensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job fyddres Sheet, Box, or Rou� �� � City ��� Z�p��
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Section No. Township Name or No. Range No. Fire No. County .
�� � Phone No.
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Power Supplier � Address
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Electri nhacror / Company Name � � Contractor License No. Master Lic. No. (Plant Elect Only)
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Mailing Address (Coniractor, Co pa or Own Performing Installafion)
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Authorized Signafure (Confracfor, C, pany or Owner Pe ming Insfallafion) Phone Numbe
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EB"OOOO�A-�2 5/�999 STATE BOAR OPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY