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Home Duplex
Com merc ial Ind ustrial
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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
Apt. Bldg. Other. ew Addn
Farm emod Re air
Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
request. Enter remarks in this space and on the back of the whiie copy only.
Calculaie Inspection Fee - This Inspecfion Requesf will not be accepted without the correci fee:
Other Fee # Service Entrance S' e Fee # Circuits/Feeders
Mobile Home Park Stall 0 to� 90 Amps 0 to 100 Amps
Sfreet Ltg./Traffic Sig. Above 200 Amps Above 100 Amp;
Transformer/Generator INSPECTOR'S USE ONLY T�TAL
Sign/Oudine Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
Fee
I hereb certi that I ins ted the electrical installafion deuribed herein o� the dates slated
Irrigation Boom Ro�gM� pa
Special Inspection U"' 9
F�nal p� _�
Investigative Fee ` _„"�^_ � �_
THIS INSTALLATION MAY BE ORDERED DISCON D IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request wid 18 months 6om validafion date printed in this box.
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* 0 4 0 0 9 2 1 3� "'' �7�
PLEASE PRINT OR TYPE
Request Dafe Rou Ffin ins fion r uired?
g pec eq Yes ❑ No Inspecfion Olher lhan RougMn: ❑ Ready Now Will Call
�`fou must call fhe i�specfor when ready) DaTe Ready:
I, icensed contractor ❑ owner hereby request inspection of the above elechical work at:
Job Address (Sheet, Box, w Roufe No.) Ciy • Zi Code
� � lZ I �D C.:e. a
Secfion No. Township Name or No. Range No. I Fire No. County
flv�a�r�
Occu�t Phone No.
Elecfrical Conhactor (Comparry Name) Contractor License No. Masfer Lic. No. �Planf
pn
Mailing Add �ne tall
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Authorized Sig hacfo r Owne erfAtming InstallaKon) �� Phone No.
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B�00001 A-i l 8/96 STATE BOARD COPY - SEE INSTRUCnoNS oN eacK � vFi � nw rnav