P - 84204� 15�4�9-874 �
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REQUEST FOR ELECTRICAL IIVSPECfiION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
New
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Commercial Industrial Farm Remod Re
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enier remarks in this space and on the back of the whife copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders
Mobile Home Park Stall 0 to 200 Amps S:o� 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Ar
Transformer/Generator INSPECTOR'S USE ONLY TO'L
�tline Ltg. Xfmr.
:emote Conhol
ig Pool
I
i Boom
InsaeiF�iC � !1
that I inscected the electrical insfallation described herein on the dafes
Fee
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THIS INSTALLATION MAY BE ORDERED DISCONNEGSFB'�F NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This request void 1 S monfhs from validation date printed in fhis box.
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* 0 5 4 9 8 7 4 6* PLEASE PRINT OR TYPE
Request Dafe Rough-in inspection required? ❑ Yes o Inspecfion Ofher Than Rough-In: eady Now � Will Call
l�— �% r�� (You must call ihe inspector when ready) Date Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sfreet, Box, or Route No.� Ciy Zip Code
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Secfion No. Township Name or No. Range No. Fire No. Couny
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Occupant Phone No.
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Power Supplier Address ^
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Ele rical nhacfor (Company Name) Contracfor License No. Masfer Lic. No. (Plant Elecf. Only)
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Mailing Address �Conhactor or Owner Performing Installation)
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Auf riz Signature �Confracfor or Own r Performin al afion) A� Phone No.
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B4 1A-11 B/96 STATE BO CO Y- SEE INSTRUCTIONS ON BACK OF YELLOW COPY