P - 81470REQUEST FOR ELECTRICA�.,l�lS�„ECTION
7�1. 112 � Minnesota State Board of Electricity
1� 1821 University Ave., Rm. S-128, St. Paul, MN 55104 �
� Phone (612) 642-0800
Home Duplex Apt. Bldg. Other:�f/f / ,/ ew Addn
Commercial Indusirial Farm //"' ��/ �`� Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" obove Ihe work covered by this request. Enter remarks in this space and on the back 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 p, o Q
Street Ltg./Traffic $ig. Above 200 Am s Above 100 Amps
Transformer/Generafor INSPECTOR'S USE ONLY TOTAL
$ign/Outline Ltg. Xfmr. � `��
Alarm/Remote Control
Swimming Pool
I hereb cerfi ihat I ins cted the elecirical installafion described heiein on fhe dafes sfated
Irrigation Boom Rough-In Date
$peciallnspecti `
Investigative Fee F��al � oe� ^�� 9
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THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 monfhs f�om validation dafe prinfed in fhis box.
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PLEASE QRINT OR TYPE
Requesf Dafe Rough-in inspecfion required? ❑ Yes No Inspection Ofher Than Rough-In:�.1� Ready No ill Call
(You musf call fhe inspecfor when ready) Date Ready: ���,� �i Si!
I, � licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address �Sheef, Box, or Roufe No.) �^ �.� ��f�jr � r Zip Code
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Secfion No. Township Name or No. Ra ge No. Fire No. Cou ty
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� Power Supplier
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Address
Company Name)
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ihac orf or Owner Performing Insfallation�
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(Contractor or ner P o ng Installation) ,
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Phone No.
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Conhacfor License No.
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Master Lic. No.
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'hone No.
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