P - 84654REQUEST FOR ELECTRICAL INSPECTION
4 Z�"j �, O�� 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 Hh. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by ihis requesi. Enter remorks in �his space and on ihe back of the whiie copy only.
Calculate Inspection Fee - This Inspection Request will not be accepted wifhout 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 Am s Above 100 Amps .—�
Transformer/Generator INSPECTOR'S USE ONLY T L
Sign/Out�ine Ltg. Xfmr.
Alarm/Remote Confrol
Swimming Pool
I hereb certi fhaf I ins the eleclrical insfallafion described herein on the dafes sfated
Irrigation Bo Rou Mn Date
Special Insp 9 -���"�`� � 6
final I�
Imestigative Fee %G -- � /� : �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPIETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This request void 18 months 6om validafion dote prinfed in this box.
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* O 4 7 O O 3 7��K �� PLEASE PRINT OR TYPE ��
Raquesf Dafe Rou h-in ins fion r uired? es
g pec eq ❑ No Inspection Other Than Roughan: ❑ Ready Now ❑ Will Call
� (You must call the inspecror when ready) Date Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electrica) work at:
Job Address �Skcet, Box, or Rou�e No.) Cify � Zip Code
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Sectio�No. � Township Name or No. Range No. Fire No. County A ,
Occupanf Phone No.
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Power Supplier Address
for �Company Name) Conhacfor License No. Master Lic. N�
; �cC.�.� �i�'_ ��fZ
(Conhactor or Owner Performin Insfallalion)
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