P - 81509REQUEST FOR cLECTRICAL INSPECTION
7!-� V- 6 0 6 Minnesota State Board of Electricity
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 C Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this requesi. Enter remarks in this space and on ►he back of the white copy only.
Calculafe Inspection Fee - This Inspection Request will not be accepied wifhoui the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/F ders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to '
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL SO
Sign/Outline Lfg. Xfmr. /J`�
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins fed the elecfrical installafion dexribed herein on fhe dates stated
Irrigation Boom Rooq�rr oare
Special Inspecti
F11f�h� . �} Da � .
Investigative Fee ' c� ,�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WI IN 18 ONTHS.
OFFlCE USE ONLY This request void 18 monfhs from validafion dafe printed in fhis box.
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PLEASE PRINT OR TYPE
Request Dafe Rouglrin inspection required? ❑ Yes No Inspection Ofher Thon Rough-In: Ready Now ❑ Will Call
`'3 ��' —�� (You musf call the inspedor when ready) Dafe Ready: �
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
1ob ddress (Sheef, Box, or Route No.) City Zip Code
S9�-woe b c.•4�E �R� o t,� y
$ection No. Township Name or No. Range No. Fire No. County
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Occupanf Phone No. G /2 �
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Power Supplier Address
Electrical Confractor (Company Name� Conhactor License No. Master Lic. No. (Planf Elett. Only�
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Moiling Address (Confracfor or Owner Performing Installafion)
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Authorized Signature (Conhactor or Owner PerformiJg Insfallafion� Phone No.
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