P - 83767REf�UEST FOR ELECTRICAL INSPECTION �..
4.0 O- 9 3 9 Minnesota State Board of Electricity
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 the work covered by this request. Enter remarks in this space ond on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall ro 00 Amps � 0 to 100 Amps
Street Lig./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOT�' � n
$ign/Outline Ltg. Xfmr. �
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins cted ihe elecirical installafion described herein on the dafes sfated
Irriqation Boom Rouah-In ��
�THIS INSTALIATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 1 S months from val'dati date printed in this box.
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Request Date � Rough-in inspection required? ❑ Yes �Jo Inspecfion Other Than Rough-In: ❑ Ready Now„� Will Call
"� �� �� (You must call ihe inspector when ready� Date Ready:
I, �licensed contractor ❑ owner hereby request inspection of the above electrical work at:
1ob Address (Street, Box, or Route No.) Ci�Y % ZiP C°de
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Secfion No. Township Name or No. Ronge No. Fire No. C unty /
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Occu t ) Phone No.
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Power Sup lier� Address
7
Elechical Contractor (Company Name) Conhacfor License No. Master Lic. No. (Planf Elecf. Only)
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Mailing Address (Conhactor or Owner Performin Installation�� � ��,/0 �
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Authorized Signature (Conhactor or ner Performing Inst o Phone No.
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EB-00001 A- 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY