P - 81029�0�°153 �
Home Duplex
Commercial Industr
Air Cond. Htg. E�
Dryer Range
"X" above ►he work coverea
REQUEST �OR ELECTRICAL INSPECTION
Minnesota State Board of Electricity �
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800 "�'
Apt. Bldg. Other �(,1 Ne Addn
Farm /� �� � emod Re air
Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
this request. Enter remarks in this space and on the back of Ihe white copy only.
Calculate Inspection Fee - This Inspection Request will not be accepted wiihout ihe correct fee:
Other fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generaror INSVECTOR•s us� e oN�v � r � TOTAL�� s�
$ign/Outline Ltg. Xfmr. �icp'c�"'' !�" --`o
Alarm/Remote Conhol
Swimming Pool
I hereb certi that I ins the elechical insmllation described herein on the dates stated
Irrigation Boom RougMo ` /-j
Speciallnspecti r '�
Final � Date
Investigative Fee �
THIS INSTALLATION MAY BE ORDERED DISCONNEC NOT COMPLETED WITH N 18 MONTHS.
OFFICE USE ONLY This rnquest void 18 months fram validation date printed in fhis box.
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PLEASE PRINT OR TYPE
Requesf Dafe Rough-in inspecfion required2 es ❑ No Inspecfion Other Than RougMn: ❑ Ready Now ❑ Will Call
/O g � (You musf call fhe inspector when ready) Date Ready:
I, ❑ licensed contractor�wner hereby request inspection of the above elechical work at:
Job Address �Sheet, Box, or Roure No.) Ciy J Zip Code
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Section No. Township Name or No. Range No. Fire No. Couny
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Occu nf Phone No.
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Power Supplier Address ,�/� A
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Elechical Confractor (Company NameJ Conhacfor License No. Maskr Lic. No. (Planf Elecl. Only)
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Mailing Address (Conhactor or Owner Performing Installalion)
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Authorized Signature �Conh or Owner Performing Insla o � Phone No.
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E&00001 A-11 8 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY