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REQUEST FOR ELErTRICAL INSPECTION
Minnesota State� Board of�Electricity
1821 University Avenue Suite 5-128, Saint PaW, Minnesota 55104-2993
(651) 642-0800 www.electricity.state.mn.us �"� ;
Apt Bldg. Other: Ne�,y� /
Farm Remod F
Water Htr. Load Mgmt. Other:
Elec. Heaf Temp. Service
his request. Enter remarks in this space ond on the back of the white copy on
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Calculate Inspection Fee - This Inspection Requesi will not be accepted without the correct fee:
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
' OFFICE USE ONLY This request void 18 months from validation date printed in this box.
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PLEASE PRINT OR TYPE
Requesf Date Rough-in inspection required? ❑ Yes No Inspection Ofher Than Rough-In: ❑ Ready Now � Will Call
� ��9 � You must call the inspector when ready Date Ready: � Jj =�� ���
j,� licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Jo Address (SfreetvBox,yr Roufe No.) -/f •> Gty f� Zip Code
No" I Townshio Name or No.
or
COPV
No.
SEE INSTRUCTIONS ON BACK OF VELLOW COPY