P - 84710� REQUEST FOR ELECTRICAL INSPECTION
4� 4� 41�� Minnesota State Board of Elec[ricity
� 1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800
Home Duplex Apt. Bldg. Other: New Addn .
Commercial Indusfrial Farm Remod
ir Cond. Htg. Equip. Water Htr. Load Mgmf. pfher:
Dryer Range Elec. Heat Temp. Service
"X" above the work overed by this request. Enier remarks in this spacfe and on the b('a�ck of the white copy only.
(�ft,v,� tr-Q � r.� o� C.l� C� ti G aCl L i` � 1 A C.I� .
Calculo►e Inspection Fee - This Inspection Request will not be accepted without fhe correci fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Sheet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/O�tline ltg. Xfmr. , �S ;�'�
Alarm/Remote Control
Swimming Pool
I hereb certi thaf I ins fed the electrical insmllafion dexribed herein on the dates stated
Irrigation Boom Ro�Mn pa�
--••a° .�r � p —• !
THIC INST i eT�oN ypY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS�
OFFlCE USE ONLY This request void 18 monfhs from validation date prinfed in this box.
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R� � �O� Rough-in inspeclion required2 ❑ Yes �No Inspecfion Other Than ougMn: �Ready Now ❑ Will Call
'Lt f� (You musf call the inspeclor when ready) Date Ready:
I, �,j�censed contractor ❑ owner hereby request inspection of the above elecfrical work at:
Job Addreu (Shcef, Box, or Roule No.) City Zip Code
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Secfion No. Township Name or No. Range No. Fire No. Coun
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Conkocror�Company Name�
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�ddreu (Conhacfor or Owner Perfor
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d Signature (Conhador or Owner P�
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Phone No.
onhacfor License No.
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Lic. No. (Planf Elect.
No.