P - 82067(���36-449 �
REQUEST FOR ELECTRICAL INSPECTION T"E
Minnesota State Board of Electricity °i
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993 ��`
(651) 642-0800 www.electricity.state.mn.us `��'
Apt. Bldg. Other: New Addn
Air Condifioner Htg. Equip. Water Hir. Load Mgmt. Other:
Dryer Range Elec. Heaf Temp. Service
"X" above the work covered by this request. Enter remarks in this space and or
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Calculate Inspection Fee - Thi ection Request will not be accepted without the correct fee:
Other Installations Fee # Service'.Enirance Size Fee # Circuits / Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg. / Traffic Sig. Above 200 Amps Above 100 Amps
TransFormer/Generator INSPECTOR'S USE ONLY TOT ^�
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ected the electrical insmllation described herein on the dates stated:
Irrigation Boom eoogh-lo Dare
Special lnspection
Imestigative Fee ��' -
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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 R TYPE
Request te Rough-in inspecfion required2 ❑ Yes ❑ No Inspection Other Than Rough-In: • eady Now ❑ Will Call
You must call ihe inspecfor when ready Date Ready: .
I, licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sheef, Box, or Rou�N .) � � � Cily , �� Zip Code �
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