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REGIUEST FOR ELECTRICAL INSPECTION °'E
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �
Phone (612) 642-0800
Other New Addn
Commercial Industrial Farm Remod Re
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above ihe work covered by this request. Enter remarks in this space and on the back of the white copy only.
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Calculate lnspection fee - This lnspec6on Request wi!! not be accepted wilhout the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Streef Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generaror INSPECTOR•s use oN�r TOTAL
Sign/Oudine Ltg. X�mr. —��
Alarm/Remote Control � �
Swimming Pool
I hereby certi(y that I inspecled the eleclrical installation described herein on the dates stated
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Investigative Fee �V � �� � � � - 6
THIS INSTALLATION MAY BE ORDERED DISCONN _ D IF NOT COMPLETED WITHIN 18 MONTHS.
� OFRCE l�E ONLY This requsst void 18 monfhs ban validptian da�e printed in fhis box,
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* � 5 9 °i Ea � 8 7�k PLEASE PRINT OR TYPE
Request Dafe Rough-in inspection required? Yes ❑ No Inspecfion Ofher Than RougMn: Ready No Will Call
(You must call Ihe inspector w ready) Date Ready: "7
I, licensed contractor ❑ owner hereby request inspection of the above elechical work at:
Job Address (Sheet, Box, or Route No.) � Ciy � � Zip Code
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Section No. Township Name or No. Range No. Fire No. n -
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Occupant ^ Pfwne No.
Power
�ry Nome� Conhactor license No. Master lic. No. (%
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w Owner Perfo ing Inslalbtion� .
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Kior or Performing Installafion� Phone No.
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STATE 9�AR� COPY - SEE WSTRlIC710NS ON BACK OF YELLOW COPY