P - 81514REQUEST FOR ELECTRICAL INSPECTION -
5 3 2- 5 61 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 Indushial Farm emod Re air
Air Cond. Htg. Equip. Water Hh. Load Mgmt. Other: /_ /_
Dryer Range Elec. Heat Temp. Service �'< <t�l '
"X" above fhe work covered by this request. En r remarks in this space and o e back of fhe white copy only.
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Calculate Inspecfion Fee - This
Other
Mobile Home Park Stall
Street Ltg./Traffic Sig.
Tra nsformer/Generator
Sign/Oudine Ltg. Xfmr.
Alarm/Remote Conhol
Swimming Pool
Irriqation Boom
ispection Request will not be accepted wi►hout ►he correct fee:
Fee # Service Entrance Size Fee # Circuits/Feeders Fee
0 to 200 Amps 0 to 100 Amps
Above 200 Am s Above 100 Amps
INSPECTOR'S USE ONLY TOTAL
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I hereby certify that I inspectea th�el�ical installafion described herein on the dotes �����
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Investigative Fee � eQ.�! �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validation date prinled in this box.
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Requesf Date R h-in ins on r uired?
«ig pecti eq es ❑ No Inspection Other Thon RougMn: ❑ Ready Now ❑�II Call
��q �� � (You must call the inspecfor whe ready) Date Ready:
I, ❑ licensed confractor �owner hereby request inspection of the above elechical work at:
Job Address (Sheet, Box, or Roufe No.) City Zi Code
(� r� �rr h N� ��� �.�, $S v 2
Seclion No. Township Name or No. Range No. Fire No. Counly
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Power Supplier Addre
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Elechical Conhacror �Company Name)
Moiling Address (Confracfor or Ownef Performing InstallaKon)
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Aulhoriz S' nature (Confr��iq�or Owner Performing Installafion)
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&00001 A-11 8/96 STATE BOARD COPY - SEE
Phone No.
Conhacfor license No.
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Phone No.
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