P - 81500♦
-�32-559
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REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-08
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Home Duplex Apt. Bldg. Other. ` �' ��� New Addn
Commerciai Indushial Farm �i Remod Re ir
Air Cond. Htg. Equip. Water Hfr. Load Mgmf. Other:
Dryer Range Elec. Heat Temp. Service
"X" above fhe work covered by this request. Enter remarks in this space and on the back of ihe white copy only.
�'D IAc.F! � � '� t�tt/S�� {�e� L,r�(DU $1 �1.0 ��Q k e � %�c.�.
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Calculate Inspection Fee - This Inspeciion Request will noi be accepted without ihe correct fee:
Otfier Fee # Servi e Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 00 Amps 0 to 100 Amps
Sheet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Oudine Ltg. Xfmr. � � �
Alarm/Remote Control
Swimming Pool
I hereb certi fhut I ins fhe eleclrical installafion dexribed herein on fhe dafes sfated
Irrigation Boom RooyMn �
Special Ins
Investigative Fee F��O� � ,1
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THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WI IN 18 MO
�� OFF�CE USE ONLY This request void 18 monlhs from validation date printed in Ihis box.
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PLEASE PRINT OR TYPE
Request Da R h-in ins on r uired$
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' �You musf call fhe inspecfor when ready) pa� R�dY: 3� p
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I, licensed contractor ❑ owner hereby request inspecfion of the above elecfrical work at:
Job reu �StreM, Box, a Roupe No.) Ci Zip Code
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Section No. iownship Name or No. Rang� o. Fire No. County
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occopaor ��'�
I� � Phone No.
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Power Suppliar Addre
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Eleci,ical Conhacfor ( punY me) . Contracror License No. Master Lic. No. �Plant Elect. Only)
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Mailing Address Contr«tor or pwner Performing Inslallalion) � �
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Authorized Si9^9Aie (CMhqclw w Owner Perfor na I��r�l4,r��,,,1 .,� ..
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- SEE INSTRUCTIONS ON BACK OF YELLOW COPY