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P - 82269U-�-�1-713 �l � REQUEST FOR ELECTRICAL INSPECTION Minnesota State Board of Electricity 1821 Universiry Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 (651) 642-0800 www.electricity.state.mn.us �� � � '�;� i� �C (� �1 t1 �� ��� Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee: Ofher Insfallations Fee #$ervice Enhance Size Fee # Circuits / Feeders Fee Mobile Home Park StaA 0 to 200 Amps 0 to 100 Amps Street Ltg. / Tra(fic Sig. Above 200 Am s Above 100 Amps Transformer/Generator INSPECTOR'S USE ONLY TOTAL Sign / Outfine Ltg. XFmr. Alarm/Remote Control Swimminp Pool iniyun�ii Pwn� • - Rough-In Date Special Inspechon Investigative Fee �10OI DZ _ 2_ d THIS INSTALLATION MAY BE ORDERED DISCON CTED IF NOT COMPLETED WITHIN 18 MONTHS. OFFICE USE ONLY This requesf void 18 mo�fhs from validatio� date printed'+n this box. I��������I������I�������������������I � aa - � � U 9 8 1? L 3 1 * �5�� PLEASE PRINT OR TYPE Request Dote Rough-in inspection requiredZ ❑ Yes ❑ No Inspection Ofher Than Rough-In: �[teady Now 0 Will Call �— � You musf call the inspector when ready Date Ready: I,�-licensed contractor ❑ company ❑ owner hereby request inspection of the above electricaf work at: