P - 82048REQUEST FOR ELECTRICAL 4NSPECTION '"E
11 � 7� f- 5 9 5� Minnesota State Board of Electricity �� �
1821 UniversityAvenue Suite S-128, Saint Paul, Minnesota 55104-2993 =
� (651) 642-0800 www.electricity.state.mn.us '�'
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Calculate Inspection Fee - This Inspection Reques► will noi be accepied without ►he correct fee:
Other Installations • fee # Service Entrance Size Fee # Circuits / Feeders Fee
Mobife Home Park Stafl 0 to 200 Amps 0 to 100 Amps
Street Ltg, / Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY T �j
Sign / Outline Ltg. Xfmr. �OCG •��
Alarm/Remote Control
Swimming Pool
I herebvi certiH that I insoecfed the electrical installation described herein on fhe dates stated:
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Final Q
Investigative Fee �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
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OFFICE USE ONLY This requesf void 18 monfhs from validafion date prinfed in fhis box.
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PLEASE PRINT OR TYPE
Requesf Date N, Rough-in inspection required$ ❑ Yes No Inspecfion Other Than Rough-In: ❑ Ready Now Will Call
�' 3� W You musf call the inspecfor when ready Date Ready:
I, �licensed contractor ❑ company ❑ owner hereby request inspection oF the above electrical work at:
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atC Irv`.i1NUGIlUNS ON GAGK UF YELLUW COPY