P - 82376REQUEST FOR ELECTRICAL INSPECTION
6��,�� �(� � Minnesota State Board of Electricity
�, t_ J 1821 University Ave., Rm. S-128, St. Paul, MN 55104
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 o�n the y6 �k of the white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepied 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 .pd
Sheet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR's usE oN�v T�A
Sign/Outline Ltg. Xfmr. • � a
Alarm/Remote Control
Swimming Pool
I here certi that I ins the electrical installafion described herein on the dales stated
Irrigotion Boom Ro�Mn Dare
Special Inspection
Irnestigative Fee Final D O_Q �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 monfhs from validation date prinfed in this box.
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PLEASE PRINT OR TYPE
Requ st Dafe Rough-in inspection requiredZ ❑ Yes o Inspection Other Than RougMn: ❑ Ready Now all .
� Q� �Yoo musf calf the inspecfor when ready� � Dafe Ready:
I, icensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address S%ef, Box, or Route No.� City Zip Code
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Secfion No. Township Nar?�e or No. Range No. Fire No. �
Occupant. � . . . - � � Phone No.
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P r Supplier � Address '- ,�� �
_ � '�s��n _ l ' �� Or�-
Eleckical Conhactor �Company Name) Conhacror license No. Master Lic. No. �Planf Elecl. Only)
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Mailing Address (Conhacro or er Performing Ins Ilation�
�./�. � �� �.S$�J i / SSO`�d
Authorized Signature (Conhacror or Owner Performing Installation) Phone No.
Id� • s�-093�
EB-00001 A-11 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY