P - 83812REQUEST FOR ELECTRlCAL INSPECTION
51 �"- � l �� Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
,f '' Phone (612) 642-0800
�Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm t�-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 and on the back of the white copy only.
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Calculate Inspection Fee - This Inspeciion Request will not be aca
Other Fee # Service Entrance Size
Mobile Home Park Stall 0 to 200 Amps
Street Ltg./Traffic Sig. Above 200 Am
Transformer/Generator INSPECTOR'S USE ONLY
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
without the correct fee:
Fee # Circuits/Feeders Fee
0 to 100 Amps
Above 100 Amps
TOTjA,� S-�'
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. I hereb certi thaf I ins the electrical
Irriqation Boom e,,,,��„
Investigative Fee ti cJ J ��� � f_�'� C��-G-..—�—�� ��� —� %-� `
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHI 18 MON HS.
OFFlCE USE ONLY This requesf void 18 monfhs from validafion dafe prinTed in fhis box.
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* � 5 l+ 4 1 7 9 L�K PLEASE PRINT OR TYPE (`� '�
Request Date • Rough-in inspection required? ❑ Yes
/v ❑ No Inspecfion Other Than Rough-In: ❑ Ready Now ❑ Will Call
�� i D-�� (You must call the inspector when ready� Date Ready:
I, � licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sheet, Bogpr Route No.) City Zip Code
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Section No. Township Name or No. Range No. Fire No. Counly
Phone No.
/ ��� � r�s� �s`�%-�7y�
Power Supplier Address
Elecfrical Confracfor (Company Name) Conhadw license No. Masfer Lic. No. �Planf Ele
,� S�`�iP L=G��r�i� i�r� , ��3�"y
Mailing Address (Contractor or Owner Performing Installation�
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Authoriz ' ature (Contractor or Ow r Performing Installafion� Phone No.
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B-0OOOlA-1 . 8 ATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY