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ome Duplex
REGIUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-OS00 �
Other. New Addn
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C�mmPrcial Industrial Farm emo
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Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
this requesf. Enter remarks in this space and on Ihe back of �he white copy only.
Calculate Inspection Fee - This Inspection Request will not be accepted wifhouf the correcl fee:
Other Fee # Service Entrance Size fee # Circuits/Feede►s Fee
Mobile Home Park Stall 0 to 00 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Tra�sformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Outline Ltg. Xfmr. ��` �
Alarm/Remote Control ,
Swimming Pool
I hereb certi fhat I ins ted Ihe eleckic ' stallalion dexribed herein onYhe dates staled
Irrigafion Boom Rouglrin �O� : �_
Special Inspection F��al ' "�
Investigative Fee �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
2 9 9�� O 0 � OFFICE USE ONLY This request void 18 monihs from validation date printed in this box.
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PLEASE PRINT OR TYPE
Request Date y� Rough-in inspedion required2 �,Yes ❑ No Inspecfion Ofher Than Rough-In: � Ready Now �Vill Call
��� �- � j (You must call the inspedor when ready) Date Ready:
I, [� licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Street, Box, or Route No.) City Zip Code
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Section No. Township Name or No. Range No. Fire No. County
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Occupant Phone No. �
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Power Supplier Addres
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E�edrical Conirador �Company Name) Contrador License No. Master Lic. No. (Plant Eled. Only)
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Mailing Address (Conimdor or Owner Performing Installafion)
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Authorized Signature (Contrador or O ner Perfo ' g Instolfution) Phone No.
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EB-OOOOlA-10 6/95 STATE BOARD COPY- SEE INSTRUCTIONS ON BACKOF YELLOW COPY �,
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