P - 84540REQUEST FOR ELECTRICAL INSPECTION .--�..
`t �,,Q �� 5 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 Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this requesi. Enter remarks in ihis space and on the back of fhe white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepied without the correcf fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Pork Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traific Sig. Above 200 Am s Above 100 Amps
T f G TOTAL
rans ormer� enerator INSPECTOR S USE ONLY �—
Sign/Outline Ltg. Xfmr. ��J ��
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ted the electrical installation described herein o� the dates stated
Irripation Boom R,,,,,,i,a„ n,,,e
� Investigative Fee "`�� v� �._ ��C —�' � V�-1' — j i
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ODILY This requesf void 18 months from validation date printed in fhis box.
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* � 4 5 9 1 5 3 3* pLEASE PRINT OR TYPE
Request Dale Rou h-in ins fion r uired?
_^ g pec eq ❑ Yes No Inspection Olher Than RougMn: ❑ Ready Now Will Call
�^ �'� (You must wll the inspecror when ready) Date Ready:
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I, �`licensed contractor ❑ owner hereby request inspection of the above electrical work at:
lob Address (Sheet, Box, w Roufe No.) Cify Zip Code
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Section No. Township Name or No. � Range No. fire No. County
_ 14 Y�.L> I-� C�
Or.cupanf
Power
Phone No.
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Contractof (Company Name) Conhaclor License No. � MasTer Lic. No.
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Or
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or Vwner Yerjcymin�lnsfollafion� � ��hti j�[�!+y I Phone No.
BOARO CO�Y - SEE INSTRUCTIONS ON BACK OF YELLOW COPY