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Minnesota State Board of Electnaty �
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" 0 3 9 6 2 2 2 2* Phone (612) 642-0800 �_���
' Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Repair
'° Air Con Htg. Equip. Water Htr. Load Mgmt. Other:
ryer Range Elec. Heat emp. Service
"X" above the work covered by this request. Enter �emarks in this space and on the back of the white copy on�y.
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Caiculate inspeciion Fee - This lnspection Request will not be accepted without the correcf iee:
Other Fee # Service Entrance 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 TOTA �...,
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool I hereby certify that I inspected the electrical installation described fierein on the dates stated
Irrigation Boom Rough-In Date
Special lnsp
Final D �� . �j' Z
Investigative Fee c. �v'-
7HIS 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
Req s[ Dat@ � Rough-in inspection required? ❑ Yes No Irrspection Other Than Rough-1 . eady Now ❑ Will Call
�J(You must call the inspecfor when ready) Date Ready:
I, ❑ licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job�Add�(S��, or Route o.) ����� �� Cdy ����� Zip Code
C t�
Section No. Township Name or No. Range No. 'Fire No. Coun
Power Supplier
Electr I Contractor
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EB-00001A-11 8/95
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Address
Vayrf�) �� �` Cont actor Ucense No.D !� Master Lic. No. (Plant Elecl. Only)
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�w�rforming Ins[allaTi� � � � �
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r or Owner Performing Installation) � Phone N� ���
2�" ,
STATE BOARD COPY - SEE INSTR '� ^' BACK OF YELLOW COPY �
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