P - 82380REQUEST FOR ELECTRICAL INSPECTION ��
U � � ,ra � � � � p � Minnesota State Board of Electricity �
C.� � O 1821 Universiry Avenue Sui[e S-128, Sai�t Paul, Minnesota 55104-2993 �
� J (651) 642-0800 www.electricity.state.mn.us
"X" above the work covered by
s�P�,a� � a �,��
s request. Enter remarks in this space and on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accep►ed without ihe correcf fee:
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
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OFFICE USE ONLY This r uest voi 18 months from validafi te printe ' this box.
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LEASE PR{NT OR TYPE���I�
Requesf Date � Rough-in inspeclion required? ❑ Yes �No Inspection Ofher Than Rough-In: eady Now ❑ Will Call
� You musf call the inspecfor when ready Date Ready: as
I,�licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address ISheef, Box, or Route No.� � City Z�p C�
�
mship Name or Nc
Contmctor
Address (Contracror, Company or
!U ii,�irv, r�
ed Signature (Confrqctor, Compai
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Range No. Fire No. C nty
Phone No.
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Addreu
Conhactor License No. Master Lic. No. �Planl
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� P rforming installafion)
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���9 STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY