P - 81539, REQUEST FOR ELECTRICAL INSPECTION
7 c�� p�� Minnesota State Board of Electricity
J O 1821 University Ave., Rm. S-128, St. Paul, MN 55104 �
� Phone(612)642-0800
Home Duplex Apt. Bldg. Other: New Addn
Commercial Indusfrial Farm Remod Re ir
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above ihe work covered by this requesl. Enter remarks in this space and on the back of the white copy only.
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Calculaie Inspection Fee - This Inspection Request will no► be accepied wiihout the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps to ps
Sheet Ltg./Troffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL ��
Sign/Outline Ltg. Xfmr. �
Alarm/Remote Confrol
$wimming Pool
�, , � I hereb_certify ihaf I inspecfed fhe elechical installation described herein on the dafes stated
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nvestigafive ee _ —� ,,.
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
. �` OFFICE USE ONLY This request void I B months from validafion da prin in box.
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PLEASE PRINT OR TYPE
Requesf Date Rough-in inspecfion required2 ❑ Yes o Inspecfion Other Than RougMn: ❑ Ready Now ill Call
�1 �a (You must call the inspector when ready) Date Ready:
I, icensed contractor ❑ owner hereby request inspection of the above elechical work at:
lob Address (Sheet, Box, or Roule No.) City Zip Code
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Secfion No. Township Name or No. Range No. Fire No. Couny_
Occu nt
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Power $upplier Address
I Confractor (Company Name)
BIAINE HT+3. A;C E
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Masfer Lic.
2 ^ Phone No.
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