P - 81759REQUEST FOR ELECTRICAL INSPECTION
����; �;; �� � g 9� Minnesota State Board of Electricity
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"1 (651) 642-0800 www.electricity.state.mn.us
Home Duplex Apt. Bldg. Other: New
Commercial Industrial Farm emc
Air Conditioner Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
„X" above the work covered by this request. Enter remarks in ihis space and on the back of the white
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copy
Calculate Inspection Fee - This Inspection Request will not be accepted wifhout the correct fee:
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THIS INSTALLATtON MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE QNI.Y This rec{uest void 18 months kom validation date printed in this box.
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PLEASE PRINT OR TYPE
Request Date Rough-in inspection requiredZ ❑ Yes o spection Other Than RougMn eady Now 0 Will Call
� a� "'� You musf call fhe inspector when ready , Date Ready: �
I, 'censed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Jo Address (Sheef, Box, or Roufe No.) � � . City �, Zip Code
or No.
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Conhactor / Company Name
Range No. Fire No. County
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Phone No.
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Iress (ContraotDJCompany or Owner Performing Insfallafion�
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iignaf (Conhactor, Compony Owner Performing Insfallation) Phone Numb(e'�r.� �
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12 19 9 STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY