P - 80886REQUEST FOR ELECTRICAL INSPECTION "'���
�(�(� (�(�p Minnesota State Board of Elec[ricity �
I,j'U ` J 7 O � 7821 Universiry Ave., Rm. 5-128, St. Paul, MN 55104 ��
s Phone (612) 64&0800
Home Duolex Aot. Blda. Olhec New Addn
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Calculale Inspection Fee - This Inspecfion Requ�
O(her Fee � Ser
Moblle Nome Park Stall �o
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Load Mgmt. Other.
Temp. $ervice
narks in fhis space ond on e bock of the �
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will not be
e Entrance
NSPECTOR'S USE ONLY
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wi(hout lhe cor�eCf fee:
Fee # Clrcuits
0 to 100 A
herein on the dofes
�� I_TXIS INSTALLATION MAV BE ORDERED DISCONNECTED IF NOT COMPLETED N
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I���I II �II I II II III � III�I III � II I IIII OFFICE USE ONLY This request wid � 8 menths�voli
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PLEASE PRINT OR TYPE
Reqoest Da Roogh-in inspection requiredz ❑ Yes No Inspenion O�her Than Rough-In:
�S �Vov must mll Il�e Inspecmr when reody Dare Ready:
I, �licensed wntroctor 0 owner hereby request inspedion of ihe obove electrical work at:
bb yjdress (�e� :, or Rou��/ ��� / qy�r `/
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLAW COPY
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