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REQUEST FOR ELECTRICAL INSPECTION -_
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
Apt. Bldg. Other: New Addn
Farm : � Remod air
Water Hfr. Load Mgmt. Other:
Elec. Heat Temp. Service
request. Enter remarks in this space and on the back of the whiie copy only.
Calculate Inspection Fee - This Inspection Request will not be occepted without ihe correct fee: '
Other Fee # Service Entrance 'ze # Circuits/Feeders
Mobile Home Park SFall to 00 Amps 0 to 100 Amps
Sheet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'SUSEONLV � �_��� TOTAL �/�!�
Sign/Oudine Ltg. Xfmr. � 4�.,,yc., ^.•,.�,�5sit '"`��" O�lO �EJ
Alarm/Remote Control
I herebvi certiH ihot I insoected the eleckiml installation described herein on the
Investigative Fee "� ��.�/�
THIS INSTALLATION MAY BE ORDERED ECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requast void 18 moMhs from validation date prinfed in this box.
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111N1111111111111111111 IIIIIIIIIIIIIIIIIII L�
� 0 5 3 2 5 3 6 0 x� �`�rO
PLEASE PRINT OR TYPE
Requesf Da6e d Rough-in inspeclion required? ❑ Yes ❑ No Inspecfion O�er Than RougMn: (�Ready Now ❑�II Call
',/+ 3�-� b (You must call the inspecMr when ready) Dafe Ready: �
I, ❑ licensed contracror � owner hereby request inspection of the above electrical work at:
lob Addreu (Shcef, Box, w Rarte No.) Ciy Zip Code
�70 G `.cl Sr � ^iQ c d�e 2
Seclion No. Township Name or� Rang� .� I Fire No. C nly A �
7 y� 1 I�'II�- ts
�r
(� Phooe No.
!✓�% Z°. WS �o ( 2
ndd.�
/� s�/��
rv Name) Contracrorlicense No.
ess (Contracior a Owner Per(orming Inslallation)
0� ��� St Nd�.�,�'��2i�
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY
lie. No.
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