P - 84212• • � • �.
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RE(�UEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800
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,` Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re air
Air Cond. Htg. Equip. Water HTr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Requesi will not be accepied withoui the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders ee
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 ONLV TOTAL �<
Sign/Outline Ltg. Xfmr. ��"�
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ted the electrical insfallatio� described herein on the dates stated
Irrigation Boom Rougfrin Date
Special Inspecti p
F.inel -
Imestigative Fee �—� �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 monfhs from validation dafe printed in fhis box.
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* � 5 8 3 8 9 9 �* PLEASE PRINT OR TYPE
Request Date Rough-in inspecfion required? ❑ Yes ❑ No Inspection Other Than Rough-In:
' � C" S� (You musf call the inspector when ready) Date Ready:
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I, licensed contractor ❑ owner hereby request i�spection of the above electrical work at:
Job�Address (Sheei Box, or Route Nv:}--� . / City
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or No.
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�er Suppli r � :.�� A�
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:trical Conhoctor (Company Name)
'ENDABLE ELECTRIC, l(VC.
i C � � C�i}OrdgrF��j Installafion�
n Rapids, MN 55433
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horized Signafure �Co cTOr or Owner Performi g Installaf
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���— ����; ,rST�AT OARD COPY -
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Phone No.
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License No.
INSTRUCTIONS ON BACK Of YELLOW COPY
idy Now ❑ Will Call
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