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REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electriciry
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
Other: New
Farm
Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
request. Enter remarks in this space and on the back
copy
Calculate Inspeciion Fee - This Inspection Request will not be accepied wifhoui the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders
Mobile Home Park Stall to 00 Amps �j 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amp:
Transformer/Generator INSPECTOR'S USE ONLY TOT�
Sign/Outline Ltg. Xfmr. !
Alarm/Remote Control
$wimmin Pool
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Fee
9 I hereb certi fhat I ins ted the elechical insTallafion described herein on the dafes sfafed
Irrigation Boo �' j RougMn Da�e
Speciallnspec n B" °�
Final a p
Investigative Fee ,� �� r�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This requesf void 18 months (rom validation dafe prinfed in this box.
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�* � i 9 8 9 5 8$* PLEASE PRINT OR TYPE {`� `,L'�
Request Date Rough-in inspeclion required? es ❑ No Inspection Other Than Rough-In: ❑ Ready Now Will Call
D� q� (You must call fhe inspecfor when ready) Dafe Ready:
I, icensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sfreef, Box, or Roufe No.) Ci � Zip Code
I `�� C�157-� �o� C� �/��tx-�e�/
Section No. Township Name or No. Range No. Fire No. County `
Occupant
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Contractor Com an —��
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C1S1ES F �� ��.
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Confmctor License
or Owner Per%rming Insfalla� �� f!
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Phone No.
Masfer Lic. No. (Planf Elecf.