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RE(IUEST FOR ELECTRICAL INSPECTION =
Minnesota State Board of Electricity
7 1821 University Ave., Rm. S-128, St. Paul, MN 55104 -
Phone(612) 642-0800 " '
Duolex Apt. Bldq. Other: y New Addn
"X" above the work
Farm
Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
request. Enter remarks in this space and on the
white copy
Calculate Inspection Fee - This Inspection Request will not be accepted wi►hout the correci fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders
Mobile Home Park Stall to 00 A 0 to 100 Amps
Street Ltg./TrafFic Sig. Above 200 Amps Above 100 Ar
Transformer�Cienerato� INSPECTOR'S USE ONLY TO�
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Fee
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d
Swimming Pool � ���j 7
I hereb certi that I ins ected the elechical installation described herein on the. tes af
Irrigation Boom RougMn Date
Special Inspectio 'L� ` Da Z- z �,S
Investigative Fee •
�',6� _ z 97
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 months from validafion date prinfed in this box.
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* O i O O 9 O 7 2* LEASE PRINT OR TYPE
Request Date Rough-in inspection required? es ❑ No Inspecfion Ofher Than RougMn: ❑ Ready Now Will Call
I���"��j �You must call ihe inspector when ready) Date Ready:
I, icensed contractor ❑ owner hereby request inspection of the above electrical work at:
lob Address �Sheet, Box, or Route No.) City Zip Code
a Ct+�.�s�e.v�sor� LA�A�� �Mlb�-L°�
SeMion No. Township Name or No. Range No. Fire No. Couny �
�YIO}�
Occupanf ,nO � �
r:
Power Supplier � /�
S-;'
Elechical Conhacfo� (Compan N �y►�
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�.e.�stN iT 11M.. p
Mailing Addres� onhacror or Own� Performi
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Phone No.
Address
� Conhactor License No. Master
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vwner rerty/nmg mstananon� 2 4 g�^ I r
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY