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REGIUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800
Home Duplex Apt. Bldg. Other: New
Commercial Indushial Farm Remoc
Air Cond. Htg. Equip. Water Hfr. Load Mgmt. pther:
Dryer Range Elec. Heat Temp. Service
X" above the work covered by this request. Enter remarks in ►his space and on the back of the whiie copy
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Calculate Inspection Fee - This Inspection Request will nof be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feed�
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Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps �-
Sheet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTI�L �
Sign/Oudine Ltg. Xfmr. �tj
Alarm/Remote Conhol
' Swimming Pool
I her cerfi thaf I in ecled the eleclrical i�stallation described herein on the dales slated
Irriqation Boom �! � _, _ uti�i,,.. �_�
Investigative Fee —�' — �- ,�- �l%
THIS INSTALLATION MAY BE ORDERED DI ONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This requesf void 18 months 6om validofion date prinled in this box.
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PLEASE PRINT OR TYPE
Request Dafe Ragh-in inspection required? ❑ Yes No Inspecfion Other Than RougMn: Ready Now ❑ Will Call
'� !� -" �You musf call the inspecior when ready) Date Ready:
I, icensed confractor ❑ owner hereby request inspection of the above electrical work at:
lob Addreu (Sheef, Box, or Roufe No.� City Zip Code
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Seclio� No. Township Name a No. Range No. ire No. ounty �
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ElecFrical Conhacfw �Company Name)
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Mailing Address (Conhacfor or Owner PerForming In,
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Phone No.
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Address
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Contracfor license No.
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Lit. No. (Plant Elect. Onl�
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