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Home Duplex
Commercial Industrial
above the
REQUEST FOR ELECTRICAL INSPECTION =•-��.
Minnesota State Board of Electricity
1821 Uni�iersity Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800
Apt. Bldg. Other: %lew Addn
Farm Remod Repair
Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
request. Enter remarks in this space and on the back of Ihe white copy
Calculate Inspection Fee - This Inspeciion Request will nof be accepied without fhe correct fee:
Other Fee # Service Entrance ize Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 00 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Abo e 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL �D
Sign/Outline Ltg. Xfmr. a
Alarm/Remote Control
Swimming Pool
I hereb ceAi thaf I ins ted }he electrical installafion dexribed herein on the dates stated
Irrigation Boom Rough-In
Special Inspech �'� ' � %
Finai �
Investigative Fee ��'F"�-.---��_ _ �`
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 monihs from validation date prinfed in fhis box.
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* A 4 4 8 2 2 8 7* LEASE PRINT OR TYPE
Request Date Rou h-in ins fion r uired? Yes
g pec eq ❑ No Inspecfion O�er Than Roughln: ❑ Ready Now Will Call
3` .� �� �You musf call the inspecfor when ready) Date Ready:
I, icensed conhactor ❑ owner hereby request inspection of the above elecfrical work at:
1ob Address (Skeet, Box, or Route No.) City Zip Code
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Seclion No. Township Name or No. Range No. Fire No. C nty
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Occu�SF% Phone No.
Power Supplier �
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Elechical Conhacror (Company Name)
CIT�ES ELE +(`T��Ci� If�K''i.
Mailing Address (Conkacbr or Owner Pe�i
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C/100381
Insfallafion) w
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:OPY - SEE INSTRU
Conhorfor License
Lic. No.
No.