P - 82265��-969�1�� �
REQUEST FOR ELECTRICAL INSPECTION � _.
Minnesota State Board of Electricity
1821 University Avenue Suite S-728, Saint PaW, Minnesota 55104-2993 ���
(651) 642-0800 www.electricity.state.mn.us " '
"X" above the work covered by t1
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white copy only.
Calculate Inspeclion Fee - This Inspeciion Request will not be occepted without the correci fee:
Other Installations Fee # Service Enhance Size Fee # Circuifs / feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg. / Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL /}A
Sign / Outline Ltg. Xfmr. p'����
Alorm/Remote Control
Swimming Pool
I hereb certi that I ins eded the elechical installation described herein on the dates stated:
Irrigation Boom Rough-In Dare
Special Inspection
Final Da
Investigative Fee �'�'�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE U3E ONLY This requesf void 18 monfhs from validafion dafe printed in fhis box.
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PLEASE PRINT OR TYPE
Reque f Da}e Rough-in inspection required? ❑ Yes �IQd Inspection Ofher T a Roug I ady Now ❑ Will Cali
You must call the inspecror when ready Date Ready:
1, ensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Jo Ad r� i freef, Bo� or R u No.) City �� Zip Code �
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Section No. Township Name or No. Rqnge No. Fire No. CounN
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Power $upplier
Coniractor / Compam Name
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Address
J Confrocfor
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or Owner Performing Insfallation�
Phone No.
S�c� - '? a I
�. I Masfer Lic. No. (Plant
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999 ST4Te s�ARD cOPV SEE INS7RUCTIONS ON BACK OF YELLOW COPY