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REGIUEST FOR ELECTRICAL INSPECTION
� Q���� Q� � Minnesota State Board of Electricity
V V 1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
Home Duplex Apt. Bld . Other: New Addn
o mercial Industrial Farm Remo e air
Air Cond. Ht . Equip. Water Htr. Load Mgmt. Other:
Dryer Range Eiec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on ►he bock of Ibe white copy only.
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Calculate lnspection Fee - This lnspection Request will noi be accepied withoul �he correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeclers Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL O
Siqn/Oudine Liq. Xfmr. � ���
Pool
I herebvi certi(v that I insoecled the electrical installation described herein on iFie dates slaled
Investigative Fee z -�- —�
THIS II�STALLATION MAY BE ORDERED DISC CTED IF NOT COMPLETED WITHtN 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
Request �� Rough-in inspeclion required$ ❑ Yes No Inspecfion Other Than RougMn: eady Now ��II Call
(You must call the inspec�or when reody) Date Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job dress (Streei, Box, or Rou No.) . Ciy �1 ZiP Code
�1 t� � �a� ' " � �.
Secfion No. Township Name or No. Range . Fire No. Coun � �
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0
Conhncfor License No. � Master lic. No.
or
lor or Ow�Ter Performi g Installation �i � J( �•y� � " Phone No:
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STATE BOARD COPY - SEE IN UCTIONS ON BACK OF YELLOW COPY