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REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity �'
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 i�;
(651) 642-0800 www.electricity.state.mn.us " �
Air Conditioner Hfg. Equip. Water Htr. Load Mgmt.
Dryer Range Elec. Heat Temp. $ervice
"X" above the work covered by this request. Enter remarks in
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Calculate Ins c on Fee - This Insp tion Requesi wi
Other Installations Fee #$ervice Entrance Size
Mobile Home Park Stall
Street Ltg. / Tra�fic Sig.
Transformer/Generator
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool �
Irriaation Rn�rd Li s �
0 to 200 Amps
Above 200 Amps
INSPECTOR'S USE ONLY
Repair
is space and on the back of the whiie copy only.
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not be accepted without ihe corr cc� t tee:
Fee # Circuits / feeders Fee
0 to 100 Amps
Above 100 Amps
TOT�s0
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that ! ins the elechical installation described herein on the dates stated:
Date
Special Inspecfio?t' � tJ
Ffial Date
Irnestigative Fee ��.� 2- C— ad
THIS INSTALLATION MAY BE ORDERED DIS NNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 months from validafio� dafe prinfed in this box.
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PLEASE PRINT OR TYPE
Requesl Date Rough-in inspecfion required$ ❑ Yes �No Inspecfion Olher Than� Rough-In: ,c� Ready Now ❑ Will Call
�..r You musf call the inspecfor when ready Date Ready:
I, � licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at: