P - 82224REQUEST FOR ELECTRICAL INSPECTION
�� ����� � {� 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. Hig. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this spq�e qnd on the back of the white copy only.
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Calcu�e lnsp�ectrOn Yee - TIfIS RSspecho�l'k� t^�e ac� te�ihovt�correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stal) 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 TOTAL
Sign/Outline Ltg. Xfmr.
Alarm/Remote Confrol ?/ ;�O
Swimming Pool vc.a
I hereb certi Ihat I ins ted the elechical installation described herein on the dates stated
Irrigation Boom RougMn Dale
Speciallnspecti ?
Final A � \
Investigative Fee ! —��z�
THIS INSTALLATION MAY BE ORDERED DISCO ECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validafion date prinfed in fhis box.
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PLEASE PRINT OR TYPE
Request Dafe Rough-in inspeclion required? ❑ Yes No Inspection Other Than RougMn: Ready Now ❑ Will Call
' � ��You must call the inspecror when ready) Date Ready:
i, licensed conhactor ❑ owner hereby request inspection of the above elecfrical work at:
Job Address (Sheet, x, or Route No.) Ciy �/� Zip Code
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Secfion No. Township Name or No. Range No. Fire No. Co 8��
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Oc��ppnt ���. V��' �C�/� Pho� ,,� l v� Z�/ ✓ �
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Power Supplier Address
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Elechical Confmcfor (Company Name) ��,,//��/� Confracfor License No. Master Lic. No. (Plant Elecl. Only)
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Mailing Address �Conkacror or Owner erforming Insta tion)
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Au ed Signafure (Conhacfor q� Owr�r P�nstallation� Ph e No. ���
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E 1 A-11 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY