P - 825241���02-397 �1
REQUEST FOR ELECTRICAL INSPECTION -
Minnesota State Board of Electricity 3
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993 ��`
(651) 642-0800 www.electricity.state.mn.us `���
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Air Conditioner I I Htg. Equip. I I Water Hir. I I Load Mgmt. f Other:
Dryer I IRange Elec. Heat Temp. Service
"X" 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 Inspeciion Request will not be accepted without the correct fee:
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLE7'ED WITHIN 18 MONTHS.
OFFICE USE ONLY This raquesf void 1 S months from validation date printed in fhis box.
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PLEASE PRINT OR TYPE
Request, D e Rough-in inspection required$ ❑ Yes Inspecfion Other Than Rough-In: ady Now ❑ Will Call
j/ �� You must call fhe inspector when ready Date Ready:
I, icensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address (Strcet, Box, or Roufe N.J� Q Ciy Zip Code
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Secfion No. Township Name or No. Range No. Fire No. County
Occupant ,
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Power Supplier
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Mailing Address (Co cror, (
Aui orize Signa r ontraci
EB-OOOOtA-12 5/1999
� I Phone No.
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Owner P ming I tion) .
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COPY
SEE INSTRUCTIONS ON BACK OF YELLOW COPY