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REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 551044993
(651) 642-0800 www.electricity.state.mn.us
Mgmt.
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Addn
his request. Enter remarks in this space and on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
� OFFICE USE ONLY This requesf void 18 monfhs from validafion dafe prinfed in this box.
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PLEASE PRINT OR TYPE
Request Da Roug{rin inspection required$ ❑ Yes Inspection Olher Than RouglFln: dy Now ❑ Will Call
�% ,2 3 You must call the inspector when ready Date Ready:
; icensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address (Street, Box, or Rout City Zip Code
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$ecfion No. Township Name or No. Range No. Fire No. County � /� ,�
Power Supplier ��� I Address
Elecfrical Contractor / Company Name
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Mailing Address �Coniractor, Company or Owner Performing Installafion�
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Authorized $ignatur hacfor, Com any or Owner Performing Installa
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Phone No.
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;ontracfor License No. Master lic. No. (Plant Elect. Only)
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Phone Number
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_' SEE INSTRUCTIONS ON BACK OF YELLOW COPY