P - 82165REQUEST FOR ELECTRICAL INSPECTION ��° .
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U� Q� 0�� 1 ry � Minnesota State Board of Electricity �
-L 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 -
t (651) 642-OS00 www.electricity.state.mn.us '��� �
Home Duplex Apt. Bldg. Other: New Addn
ommercial Industrial Farm Remod Repair
Air Conditioner Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Insfallations Fee # Service Enhance Size Fee # Circuits / Feeders Fee
Mobile Home Park Stoll 0 to 200 Amps 0 to 100 Amps
$treet Ltg. / Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTA
Sign / Outline Ltg. Xfmr. I
Alarm/Remote Control ���� ,
Swimminp Pool . . . . . . . . _ . _ . . . . . . .
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Speciallnsp i — �Ov
Investigative Fee � �� 2 �r °`L
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OPFICE USE ONLY This requesi void 18 months from validafion dafe printed in fhis box.
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PLEASE PRINT OR TYPE
Request Dafe Rough-in inspection required? ❑ Yes No Inspecfion Ofher Than Rough-In: ❑ Ready Now � Will Call �
� You musf call the inspector when ready Date Ready:
I,�li nsed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address �Sfreet, Box, or Roufe No.J Ciry _ . , Zip Code
Section No. � Township Name or
Occupanf
Power Su�
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Elecfrical Contractor / Compony Name
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Mailing Address (Contractor, Company or Owner Performing
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Authorized $ign e(C�nhocfor, mpa Ow er Pe n
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EB-00001A-12 5/1999 STATE BOARD COPY
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Phone No�� I
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Phone Number
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SEE INSTRUCTIONS ON BACK OF YELIOW COPY