P - 82269U-�-�1-713 �l
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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
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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.
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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: