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REQUEST FOR ELECTRIGAL INSPECTION ��
Minnesota State Board of Electricity a
1827 University Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993 ���:
(651) 642-0800 www.electricity.state.mn.us `��
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Calculate Inspection Fee - This Inspec►ion Request will nof 4Se accepied wi►hout ihe correct iee:
Other Installations Fee # Service Entrance Size Fee # Circuifs / Feeders F .
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps //
Street Ltg. / Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator JNSPECTOR'S USE ONLY TOTA�j�
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Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins cted the elechical installation described herein on the dates stated:
Irrigation Boom Ro�ah-In Dare
Investigative Fee r�oai r � � ya; : J� �� I
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THIS INSTALLATION MAY BE ORDERED DiSC NECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 monfhs kom validafion date prinfed in this box.
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PLEASE PRINT OR TYPE
Request Da � Rough-in inspection required? ❑ Yes No Inspecfion Ofher Than ugh-I : eady Now ❑ Will Call
You must call the inspecfor when ready Dafe Ready: Q
1, ' ensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Jo6 ddress (Sheet, Box,.or Route o.� City • Zip Code
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Section No. Township Name or No. .. Range No. Fire No. County .
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Power Supplier Ad�
Elechical ntractor / Company Name �
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Mailing dress (Confroctor, Co pany or Owner Performing Ins
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Aufhorized S' na e �Contracfor, panY or Owne erformin
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:B-00001A-12 5/1999 ���---
STATE BOAR� [:OPV
Phane No.
(',1�Dl�LC�a
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Master Lic. No.
Phone
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SEE INSTRUCTIONS ON HACK �F VELLOW COPV