P - 81593REQUEST FOR ELECTRICAL INSPECTION
�� � � � � � � 6 � � Minnesota State Board of Electricity
7821 University Avenue 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 Request will not be accepted without the correct fee:
Oiher Insfallations Fee # Service Enhonce Size Fee # Circuits / Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg. / Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE O�Y� �' T�AL ��
Sign / Oufline Ltg. Xfmr. ���/ / Z-�� ��
Alarm/Remote Control
Swimming Pool I herebvi ceAiH that I insoected the electrical installation described herein on the dates stated:
i
Investigative Fee " _ %''�' �
THIS INSTALLATION MAY BE ORDERED DISC NECTED IF NOT COMPLETED WITHIN 18 ONTHS.
� OFFICE USE ONLY This requesi void 18 months from validation dafe prinfed in this box.
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PLEASE PRINT R TYPE
Requesf Dafe � � Rough•in inspecfion required? ❑ Yes � o Inspecfion Ofher Than Rough-In: Ready Now ❑ WiA Call
a"' � r You musf call fhe inspector when ready Date Ready: .
I, licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sireet, Box, or Route N Ciy Zip Code
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or No. I Range No. I Fire No.
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Contractor / Company Name
1�, �-11'1 � Ir
�ddress �Confractor, Company Owner
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d'gnatu e( ntractor om ny or O
-12 �1999 STATE BOAI
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Installation� �
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No.
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Mosfer Lic. No.
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SEE INSTRUCTIONS ON BACK OF YELLOW COPY