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REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800 ' `'�'
. Other: New Addn
Remod
Commercial Industrial Farm
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of
D �v� 'e�7 o rn � ���
Calculate laspection Fee - This Inspi
Other Fee
Mobile Home Park Stall
Street Ltg./Traffic Sig.
Transformer/Generator
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
Irriaation Boom
whiie copy only.
rn Request will not be accepted wifhout the correct fee:
# Service Entrance Size Fee # Circuits/Feeders Fee
0 to 200 Amps .3 0 to 100 Amps _
Above 200 Amps Above 100 Amps
INSPECTOR'S USE ONLY TOTAL
I hereb certi thaf I ins ted the el 'cal insfallafion dexribed herein on the dates
Rougffln �� � , ��
Investigative Fee �" --�' —
THIS INSTALLATION MAY BE ORDERED DISC NNECTED IF NOT COMPLETED WI HIN 8 MONTHS.
OFFICE USE ONLY This requesf void 18 monfhs from validaficn dafe printed in fhis box.
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�K � 5 1 1 8 7�i 5�K PLEASE PRINT OR TYPE "
Request Date Rough-in inspection required? es ❑ No Inspection Ofher Than RougMn: ❑ Ready Now ❑ Will Call
�,. �. q n (You must call the inspector when ready� Date Ready:
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i, � licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sheef, Box, or Roufe No.) City Zip Code
13 - F 'cl
Section No. Township Name or No. Range No. Fire No. Coun _
Occupant
Power
Conhacfor �Company Name)
Phone No.
• � '1
Address
Confractor License No. Master Lic. No.
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ddreu (Conhacro r Owner Performing Installation)
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d Signature �Confracfor or Owner Performing Insfal
4-11 /96 STATE BOARD COP •
ON BACK OF YELLOW COPY
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