P - 82311REQUEST FOR ELECTRICAL INSPECTION
��� ('� � 3 � � � � � Minnesota State Board of Electricity
� 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
ommercial Industrial Farm Remod Repair
Air Conditioner Htg. Equip. Water Hfr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this s ace and on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Request wiii not be accepted without the correct fee:
Other Installations 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 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL G�
Sign / Outline Ltg. Xfmr. ,`�
Alarm/Remote Control
Swimming Pool
I herebvi certifv that I insoected fhe elechical installation described herein on the dates stated:
Investigative Fee t- r�oa� � I valrQ ��� , �3 I
l
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
J OFFICE USE ONLY This request void 18 months from validation date printed in this box.
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PLEASE PRINT OR TYPE
Reque i Dafe n Rough-in inspecfion required$ ❑ Yes o Inspecfion Other Than RougMn: Ready Now ❑ Will Call
✓�., � t.l You must call the inspecfor when ready Date Ready:
I, {icensed contractor ❑ company ❑ owner hereby request inspection oF the above electrical work at:
J Address (Sfreet, Bo�Route No.�� ` ip Code
Y ( ht d�vl �, ►',
Name or No. Range No.
Phone No.
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/ Comqpny ��ie� �' j _'��� i � Conhacfor License No. � Masfer Lic. No. �Planf Elecf.
actor, Company or Owner Performing Insfallation)
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�Conhacfor, Company or Owner Performing Installafion) f Phone
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STATE BOAR COPY SEE INSTRUCTIONS ON BACK OF YELLOW