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REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800 `'�'
Commercial Industrial Form Remod ✓ Ke i
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above ihe work covered by this request. Enter remarks in this space and on the back of the white copy only.
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Calcula►e Inspection Fee - This Inspection Request will not be accepted withouf the correct fee:
Other Fee # Servi e Entrance Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to s 0� 0 to 100 Amps / p7-
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTdIi'S iISE ONLY TOTAL �!�
Siqn/Outline Ltp. Xfmr. � -
that I insoected the elechical insmllafion described herein on the dates smted
Speciallnspec � ��� �
Final - Dafe
Investigative Fee �cs��
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONYHS.
OFFICE USE ONLY This roquW void 1 B months 6om validation date printed in this box.
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PLEASE PRINT OR TYPE
Requesf D e Rough-in inspecfion required? ❑ Yes o Inspecfion O�er Than Rough-In: eady Now ❑ Will Call
O��S/yi (`/ou must call the inspecfor when ready) Date Ready:
I, l�licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Shcet, Box, or Route No.) Ciy Zip Code
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Secfion No. Township Name or No. Range No. Fire No. ounty �
I Con}racfor (Company Name)
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Address �Confmctor or Owner PerForming I
Phone No.
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Signature �C tra r or Ow er P rforming I Ilafion) � Phone No.
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��$� STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY