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REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 Univeisity Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993 ��r
(651) 642-0800 www.electricity.state.mn.us
Other: New Addn
Repair
Air Conditioner Htg. Equip. Water Hfr. Load MgmL Other. - I
Dryer Range Elec. Heaf Temp. Service
"X" above the work covered by ihis request. Enter remarks in this space and on the back of the white copy only.
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Calculate Inspection Fee - ihis Inspection Request will not be accepted without the correcf tes.•
Other Insto{lations Fee # Servic h ' e fee # Circuits / feeders Fee
Mobile Home Park Stall 0 to 100 Amps
Street Ltg. / Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TO�I,,�' � D
Siqn / Outline Ltq. Xfmr. �J
1 herebvi ceAiH that I insoected the electricol instollation described herein on ihe dates sioled:
� � Irnestigative Fee � � � ,/� � �-C� —{/
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
� OFFICE USE ONLY This request void 18 monfhs from validafion date printed in this box.
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PLEASE PRINT OR TYPE
Request Date Rough-in inspection required? ❑ Yes o Inspection Other Than Rough-In: ❑ Ready Now ill Call
�'r �'"� You musf call fhe inspector when ready Date Ready:
ti.
I,�licensed contractor ❑ company ❑ owner hereby request inspection of the obove electrical work at:
Job Address (SMeet, Box, or Route No.) Ciy Zip Code
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Seclion No. � Township Name or No.
Power
Range No. � Fire
55304
iny or Owi
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STATE BOARD COPY
Phon�� � � ��/
License No.
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SEE INSTRUCTIONS ON BACK OF YELLOW COPY