P - 82263� REQUEST FOR ELECTRICAL INSPECTION
�U - 9 6 9-� U o � Minnesota State Board of Electricity �_
1821 University Avenue Suite S-128, Saint Paul, Minnesota 551044993
(651) 642-0800 www.electricity.state.mn.us '��'
on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Request will nof be accep►ed without the correct fee:
Other Installations Fee # Service Enhance Size Fee # Circuits / Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg. / Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL O,
Sign / Outline Ltg. Xfmr. •
Alarm/Remote Control
_............a . __.
I hereb certi that I ins ted the elechical installaiion dexribed herein on the dates stated:
Irrigation B Rough-In Dote
Special Inspection
Investigative Fee Final Dafe Z_
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OfFICE USE ONLY This requesf void 18 monfhs from validation dafe printed in this box.
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PLEASE PRINT OR TYPE
Reque afe Rough-in inspection required8 ❑ Yes o Inspecfion Ofher Than Rough-In: dy ow � Will Call
You musf call fhe inspector when ready Date Ready: Db
I, icensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at: I
J b Address (Sheef, Box,.or No.) City • Zip Code
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Section No. Township Name or No. Range No. fire No. Couny
Occupa � � ���� �� Phone N�� � ^ I � � �
Power Supplier � � (��� � /
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Elecfric Contracfor / Company Name �
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Mailing Ad ess (Confractor, Co ny or pwner PerForming
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Authorized Si na re( onfrac r, Compny or Owner Pe rrt
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EB-00001A-12 5/1999 STATE BOAR COPY
Licenpe No. � Masfer Lic. No.
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SEE INSTRUCTIONS ON BACK OF YELLOW COPY