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Home Duplex
Commercial Industrial
Air Cond. Htg. Equip.
Dryer Range
"X" above the work covered by this
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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
farm
Water Hh. Load Mgmt. Other:
Elec. Heat Temp. Service
request. Enter remarks in this space and on
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the white copy only.
Calculate Inspeciion Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Ai
Transformer/Generator INSPECTOR'S USE ONLY I� G TOT,
Sign/Outline Ltg. Xfmr. ' J
Alarm/Remote Control
S � P I
Fee
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I hereb certi that I ins ted the electrical installation described herein on the dates stated
Irri9ation Boom RougMn � Date �7
Special Inspection i � � � /
` Final 2
Investigative Fee '
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFflCE USE ONLY This requesf void 1 8 monihs from validafion dafe printed in fhis box.
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Request Dr�ate Rough-in inspection required? ❑ Yes No Inspection Ofher Than Rough-In: ❑ Ready Now ill Call
��„ ��� (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 (Sheet, Box, or Roufe No.) City Zip Code
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Section No. Township Name or No. Range No. Fire No. Co ly
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Mailing Address
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Address
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ny Name
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or Owner Performing Installati�
uior or Owner Performing In allation)
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License No.
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Master Lic. No.
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Phone No.
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