P - 83912RE(�UEST FOR ELECTRICAL INSPECTION
���e O 4� � Minnesota State Board of Electricity
0 1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800 `'�'
- Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other: ,
Dryer Range Elec. Heat Temp. Service
"X" above.rthe work covered by fhis request. Enter remarks in ihis space and on the back of the white copy only.
%�E'ti i � i.'..� — i�.L :.. 1 �:-Z , $ �
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entranc S' Fee # Circuits/Feeders Fee
Mobile Home Park $tall / 0 to 00 Amps S �G 0 to 100 Amps ,S`�
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps .3—b
Transformer�Generato� INSPECTOR'S USE ONLY TO�A� `
Sign/Outline Ltg. Xfmr. j�(� ��. �-c�' ,v'�" �
Alarm/Remote Control
Swimming Pool
I hereb cerfi that I ins ted the elecnical installation described herein on the dates stated
Irrigation Boom RougMn Date
Special Insp
Final _ D
Investigative �
THIS INSTALLATION AAAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 monfhs from validafion dafe printed in fhis box.
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I IIII II ��I I) II� I) III II II) �) � II II) II I�I I I�I �
* � 4 1 � 8 4 3 7* PLEASE PRINT OR TYPE �5'�L�
Requesf Daf Rough-in inspection required? ❑ Yes o Inspection Other Than Rougfrin: �eady Now ❑ Will Call
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I, licensed conhactor ❑ owner hereby request inspection oF the above electrical work at:
J Address (SMeef, Box, or Roufp� No.) City Zip Code
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Section No. Township Name or�lo. Range No. Fire No. County
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Occupant Phone No.
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Power Supp ier �' n Addre��
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Elechic Conhactor Company Name�. Conhacfor License No. Master Lic. No. (Plant Elect. Only)
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Mailing Address (Conhacfor or Owner Performing Installafion)
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Aufhorized Sian r onfrod6r or Owner Pa'G�a Installafio ._ A� Phone No.
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