P - 81498� REQUEST FOR ELECTRICAL INSPECTION --�-.
7 J 1-� 7 9 3 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 C Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by Ihis request. Enter remarks in this space and on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted without the correci 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 U$E ONLY TOTAL
Sign/Outline Ltg. Xfmr. /��/�- � i�%j
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ted the electrical installation described herein on fhe dates sfated
I�rigation Boom Rough-In pa�
Special Inspectio
Final pa
Irnestigative Fee _ _ ,L Z
_THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MON HS.
OFFICE USE ONLY This request void 18 mon}hs from validafion date printed in fhis box.
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PLEASE PRINT OR TYPE
Requesf Dafe Rou h-in ins fion r uired?
9 P� eq ❑ Yes No Inspection Other Than Rough-In: ❑ Ready Now ill Call
� (You must call the inspecfor when ready� Dafe Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sheet, Box, r Route No.) City Zip Code
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Secfion No. Township Name or No. Range No. Fire No. CounH n _
���PO"� Phone No.
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� Mailing
Confractor �Company Name) Conhacfor License No. w Masfer Lic. No. (Planf Elecf.
2�6 9 � "7 �one No.
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CTIONS ON BACK OF YELLOW COPY