P - 80537��� �
U-�87-457
REQUEST FOR ELECTRICAL INSPECTION ���"9
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Minnesota State Board of Electricity s
7821 University Avenue Suite S-72$ Saint Paul, Minnesota 55104-2993 ,�
(651) 642-0800 www.electricity.state.mn.us r:;�"=°�'
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Calculate Inspection Fee - This Inspection Request will not be accep�ed without the correct fee:
Other Installations Fee # Service Enfrance Size Fee # Circuits / Feeders
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg. / Traffic Sig. Above 200�`�.'1Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TO L
Sign / Outline Ltg. Xfmr. �
Alarm/Remote Control
Swimming Pool
I hereb certi fhal I ins ted the electrical installation described herein on fhe dates sfal
Irrigation Boom Rough-In �, pt Date� L
Special Insoection n � :t . w�� �'y
I � Investigative Fee ti��' ��"�� ����� � i�t=�_ I� p— c�! — a/ �
TH{S INSTALLATION AAAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS_!
OFFICE USE ONLY This request void 1 8 months from validation date printed in this box.
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PLEASE PRINT OR TYPE
Request Date Rou h-in ins ection re uiredZ ❑ Yes
g p q ❑ No Inspection Other Than Rough-In: ❑ Ready Now � Will Call
�• ��' � You musf call fhe inspecfor when ready Date Ready:
I,�licensed conhactor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address (Street, Box, or Roufe No.) City ! Zip Code
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wer Sup ' r,.
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lectrical Contmctor / Company Nc
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Mailing Addreu (Contracfor, Comp
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or Owner
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'� Pho�e Number
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SEE INSTRUCTIONS ON BACK OF YELLOW COPY