P - 84168REQUEST FOR ELECTRICAL INSPECTION
� Q���� nr m Minnesota State Board of Electricity
`� 1821 University Ave., Rm. S-128, St. Paul, MDI 5ff104 �
' � Phone (612) 642-0800 ° '�'
ome Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod e 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 ihe back of the white copy only.
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Calculate Inspection Fee - This Inspection Request wil! not be accepted without the correct 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 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL '
Sign/Outline Ltg. Xfmr. � 5• S� I
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ted the elechical insfallafion described herein on the dates stated
Irrigation Boom Rough-In Dafe
Special Insp
, Investigative final D � `r
THIS INSTALLATION IIAAY BE ORDERED DIS TED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY �This requesf void 18 mu�ths from validafion dafe printed in this box.
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I II�I II �fI II III I) I fl III I) III II II) II III ((III �fQ �
* � 4 9 1 1 5 � 9* PLEASE PRINT OR TYPE pC 5�`7`� I
Requesf Dafe Rough-in inspection required? ❑ Yes �No Inspection Ofher Than Rough-In: Ready Now ❑ Will Call ,
�, --- �— 9' (You must call the inspector when ready) Date Ready: I
I, � licensed contractor ❑ owner hereby request inspection of the above electrical work at:
1ob Address �Street, Box, or Route No.) Ciiy Zip Code
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Occupa�f
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Power Supplier
Address
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Phone No. r a� �%
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onhactor (Company ame) Confractor License No.
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�ss � hacfor or Owner P�rmin nstallafion� //� �`�
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or
Master Lic. No.
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