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REQUEST FOR ELECTRICAL INSPECTION �
Minnesota State Board of Electricity 3
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993 ���
(651) 642-OS00 www.electricity.state.mn.us `' '
Home Duplex Apt. Bldg. Other: New
Commercial Industrial Farm Remod
Air Condifioner Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heaf Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy
Calculate Inspection Fee - This Inspection Request will nof be accepted without the correct fee:
Other Installations Fee # Service ance Size Fee # Circuits / Feeders fee
Mobile Home Park Stall ( 0 t 0 mps �j 0 to 100 Amps /'
Street Ltg. / Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY �/�,�,� TOTl�L2 g�
Sign / Outline Lfg. Xfmr. � C7V� -� �/'�'y � °�� ' "- -"� r7� '�
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ected the elecfrical installation described herein on the dates slafed:
Irrigation Boorrh �, Ro„ah-i„ i^—, I_1 Date /_7 rw _�.
� � Investigative Fee �"� � �f ���' �'-Q( �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
� OFFICE USE ONLY This requesf void 1 8 monfhs from validation dafe printed in }his box.
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PLEASE PRINT OR TYPE
Request afe Rough-in inspection required2 [�'Yes ❑ No Inspection Ofher Thon Rough-In: ❑ Ready Now � Will Call
Q°p� "� You must call the inspecror when ready Date Ready:
I, licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sfreef, Box, or Roufe No.) Cily �, Zip Code
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Secfion No. Township Name or No. Range No. Fire No. Counly �
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Power Supplier Address
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Elecfrical Conhacfor / Company Name Contracbr
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Maili Address (Conhacfor Company or Owner Performing Insfallafion)
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4uf rized Signafure (Contracfor, Com o Owner Performing Insfallation�
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Phone No. /
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Phone Number
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SEE INSTRIlCS10NS ON BACK OF YELLOW COPY