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REQUEST FOR ELECTRICAL INSPECT�ON `��
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Minnesota State Board of Electricity 3
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55704-2993 =
(651) 642-0800 www.electricity.state.mn.us '� '
Apt. Bldg. Other: New Addn
Farm Remod Repair
Air Conditioner Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the whiie copy
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Calculate Inspection Fee - This Inspection Request will not be accepted without ihe correct fee:
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONIY This request void 18 months from validation date printed in this box.
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PLEASE PRINT OR TYPE
Requesf Date Rough-in inspecfion required? ❑ Yes ❑ No �Inspecfion Other Than RougMn: �eady Now ❑ Will Call
3' t— 6 6 You musf call the inspector when ready Dafe Ready:
I, licensed contractor ❑ company ❑ owner hereby request inspection of the above elechical work at:
Job Address �Streef, Box, or Route�o.) Ciy Zip Code
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�� Township Name or No. � Range No. Fire No. Cou
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Occupanf _ , Phone No.
Powar Supplier
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Elechical Conhactor / Company Name
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Mailing Addren (Contrador, Company or
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Address
. Conhacfor License No.
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rming Insfallafion) .
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Masfer Lic. No:
ure (Conhacror, Company or Ow tallation{' Phone Number
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999 STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY