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REGIUEST FOR ELECTRICAL INSPE�IQf�J ��
Minnesota State Board of ElecVicity �
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800
Other: �lew Addn
Remod Repair
Air Cond. Htg. Equip. Water Hir. Load Mgmt. Other:
D er Ran e Elec. Heat Tem .$ervice
"k' above the work covered by this request. Enter remarks in this spoce and on fhe back of the whita copy only.
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cu ec ion ee - This Inspection Request will not be accepted without the correct fee:
Olher Fee � Service Enirance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall / 0 to 00 Amps a$'. �%Q 0 to 100 Amps �
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'SUSEONLY �o� �rt�� .T TOT L �
Sign/Outline Ltg. Xfmr. �a/t � A�a� �/G `� � � �
Alarm/Remote Control � �ryC�r<<� �Cc� T �
$wimming Pool /�-� � � ��
I hereb certi fhat I ins ected the elechical inst lation described herein on the dales stated
Irrigdtion Boo Rou h-In Da
Special Inspe � ►� 9 �� � -�� � � � ��
Final % Da � Z�
Investigative Fee - �— 7 O
THIS INSTALLATION MAY BE ORDERED DISCON ED IF NOT COMPLETED WITHIN 18 MONTHS.
2 9 9— 3 9 3� OFFICE USE ONLY This request void 18 months from validation date printed in this box.
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PLEASE PRINT OR TYPE �
Request Dqie Rough-in inspedion required2 Yes � No �nspection Other Than Rough-In: � Ready Now � Will Call
�� iS / 9 (You must call the inspector when ready) Date Ready:
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I, ❑ licensed contractor� owner hereby request inspection of the above electrical work at:
Job Address (Street, Box, or RouM No.) Ci1y Zip Code
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$ection No. Township Name or No. Range No. Fire No. Counly
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Occupanf
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Power Supplier
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Eledrical ConTracfor (Company Name)
( /��Q.�
Mai�dress (Contracior or Owner Performinq InstallaKc
Authorized
EB-OOOOiA-10 6/95
Phone No.
Contrador License No.
or p/wner e rming InstryNafion) %� J�'/ Phone No.
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY