P - 83797REQUEST FOR ELECTRICAL INSPECTION
,� � 0� C� C�1 Minnesota State Board of Electricity
�1 4� 4a 1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-OS00
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod e air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by fhis 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 # Serviee tranc Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall to Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
�ign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ted the electrical installation described herein on the dates stated
Irrigation Boom RougMn Date
Special Ins
Final Da �
Investigative Fee - �;'��---�_
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WI IN 18 ONT .
OFFICE USE ONLY This requesf void 18 monfhs from validafion dafe prinfed in this box.
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PLEASE PRINT OR TYPE
R uest Dofe Rou h-in ins on r uired?
g pecfi eq ❑ Yes o Inspection Other Than Rough-In: ❑ Ready Now�'VJill Call
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(You must call the inspecfor when ready) Date Ready:
I, �icensed contractor ❑ owner hereby request inspection oF the above electrical work at:
)ob Address (Streef, Box, or Route No.) City Zip Code
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Secfion No. I Township Name or No. I Range
Occupanf
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Power Supplier Addre:
-e-c�hica-1 Contrador (Company Name)
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Mailing Address �Confractor or Owner Performing Insfallafion�
Phone No.
License No. � Master Lic. No. (Planf Elecf. Only)
Authorized Sign e n ctor or Owner P rmi nsfallation� ���, Phone No.
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��� �� � TE ARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY