P - 83283REGIUEST FOR ELECTRICAL INSPECTION �
6�: �+ = 3 9� � Minnesota State 8oard of Electricity
�.•-r 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 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 the bacic of the white copy only.
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Calculate Inspection Fee - This Inspection Request will 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
Sireet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTA� S�
Sign/Outline Ltg. Xfmr.
Alqrm/Remote Control
Swimming Pool
I
Irriaation Booi�i !a r . �� �
Ihat I insnecled fhe elechical insfallafion
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on the dates stated
Date
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Invesfigative Fee "'Z� �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from wlidation d te rinted in this box.
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PLEASE PRINT OR TYPE
Request Date Rough-in inspection required? ❑ Yes No Inspection O�er Than Rough-In: ❑ Ready Now �� Will Call
b���� �`(ou musf call the inspecror when ready) Date Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address heef,lBox, or� Route��� �� C�y�, Z�P C�Q
w .i��`� ' (/V � �
Secfion No. Township Name or No. Ranpe No. F e No. Countv .
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Power S�pplier � Address
Elechical Conhactor (ComPany�lq�pgl�. w�,^ C, C^,r.,'NC.
Bt,A1NE M1�3 .�uv �r�v
.E.
Mailing Addreu �Co�fracfor or Lbarr.P,acForoy� ��i�
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Phone No.
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No. � Masier Lic. No. �Pla
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY