P - 83199REf�UEST FOR ELECTRICAL INSPECTION �
5 � 2- 4 9 7 Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �
• Phone (612) 642-0800
Home Duplex Apt. Bldg. Other: CC�je. New Addn
Commercial Industrial farm C7 5 Remod Re air
Air Cond. Htg. Equip. Water Htr. load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this requesi. Enter emarks in this space and\on the back of the white copy only.
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Calculate Inspection Fee - This Inspecfion Request will not be accepted without fhe correcF fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONIY TOT�� �
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Sign/OuNine Ltg. Xtmr.
Alarm/Remote Confrol
Swimmina Pool
tfwt I insoecled the
herein on the da
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� Invesfigative Fee � � C_���r � — � I�O'—/ -�� J"
THIS INSTALLATION MAY BE ORDERED dSCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This request void 18 months from validafion da�e printed in this box.
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* 0 5 3 2 4 9 7 5�C �'�'�./ /'pLEASE PRINT OR TYPE
Request Date Rou h-in ins on r uired$ ❑ Yes
9 pecfi eq ❑ No Inspeclion Olher Tfwn Raigh-In: ❑ Ready Now 0�11 CaU
�-1g -q g (You must call the inspector when ready) Date Ready:
I, ❑ licensed contractor � owner hereby request inspection of ihe above electrical work at:
lob Addreu (Street, Box, or Route NoJ Ciy Zip Code
S � � r:,� � Ss'{ 3z
Seclion No. Township Name or No. � Ra�e No. Fire No. � Counfy
Occupant
Mailing Address (Conkador or Owner
or
Pho�e No.
S
Conhacror license No.
- �13g 3
STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY
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