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REQUEST 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: NE
Farm Re
Water Hh. Load Mgmt. Other:
Elec. Heat Temp. Service
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ihis reqvest. Enter remarks in this space and on fhe b�ck of the white copy only.
Calculafe Inspection Fee - This Inspection Request will not be accepfed wifhout fhe correci fee:
Other Fee # Service Entrance Size Fee # Circuits/Feec
Mobile Home Park Stall 0 to 200 A � 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100_
Transformer/Generator INSPECTOR°S USE ONLY T
�ign/Outline Ltg. Xfmr.
Alarm/Remote Conhol
Swimming Pool
1 hereb certi that I ins the electrical installation described hefein on the
Irriqation Boom o,...,.�. �.. ..
Fee
2� C� %
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THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WIT 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validafion date printed in this box.
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LEASE PRINT OR TYPE �—
Requesf Dafe Rou h-in ins tion r uired2 ❑ Yes
9 P� eq ❑ No Inspeclion O�er lhan RougMn: ❑ Ready Now � Will Call
� ` (You must call the inspedor when ready) Dale Ready:
�, icensed contractor ❑ owner hereby request inspection of the above elechical work at:
bb Address � keet, Box, or Roufe No.) Ciy Zip Code
�,C�Q, ►�L.0 �° �--�2
Section No. Township Name or No. Range Fire No. Coun
��o K,�
Jcc�nt Phone No.
I Power
Eleclrical Conkacfor lCom n C�
CITIES EL�E��, �• MN �4
. Z�r� sT w., Ft?i?iTN.p.�.�
Mailing Address (Conhacfor or O�mer PerFo s a'onTaA'h (
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Conhacfor License
or �wner rMOrming Insfallafion�
� 25
STATE BOApD COPY - SEE INSTAUCTII
Mastcr Lic. No. (Plant Elect. Only)