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REGIUEST FOR ELECTRICAL INSPECTION ��
Minnesota State Board of Electricity _
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800 "�°"
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod� Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
D er Ran e Elec. Heat Tem . Service
"k' above the work covered by this 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 accepted without the correct fee:
Other Fee # Se ',Entrarwe Sae fee # Circuits/Feeders Fee
Mobile Home Pork $tall � 0 0 2 Amp 0 to 100 Amps
Street Ltg./Traffic $ig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'SUSEONLY TOTAL
Sign/Outline Ltg. Xfmr. " � � `� j �
Alarm/Remote Control l� t • �
Swimming Pool C����. �_ ��� �
I hereb cerfi ihat I ins eded fhe eledrical ' s I tio rib d e ein on fhe ate fed �
Irrigation Boom Ro�gh-In ��
Special Inspection ' �
Final �
Investigative Fee �— ��C'' •.l� :
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
2 9 9- 3 6 9� OFFICE USE ONLY This request void 18 monfhs from validafion daM prinfed in this box.
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PLEASE PRINT OR TYPE
Request Dste Rough-in inspection required2 � Yes � No Inspecfion Other Than Rough-In: 0 Ready Now �, Will Call
�'��. 9� (You must call the inspedor when ready) Dofe Ready:
I, ❑ licensed contracFor �'owner hereby request inspection of the above electrical work at:
Job Address (Sireet, Box, or Rouk No.) City Zip Code
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Seclion No. Township Name or No. Range No. Fire No. County
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Occupant Phone No.
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Power Supplier Address
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Eleckical C�o tratfor (Company Name) ontraclor License No. Moster Lic. No. (Planf Elect. Only)
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Mailing Addross (�cfo� r or Ow�r Perfortning InsMllofion)
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Au orized Signature (Conhador or Ownar Perfortni�g 1 Tallotion) Phone No.
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E 1A-10 6/95 STATE BOARD COPY- SEE INSTRUCTIONS ON BACK OF YELLOW COPY r �,���