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REQUEST POR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �
Phone (612) 642- 800
Apt. Bldg. Other/: � New Addn
Farm /�6 r� Remod Re air
Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
request. Enter remarks in this space and on the back of the whit�py o y.
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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 Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps Sl �Uo
Sfreet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Outline Ltg. Xfmr. ��i S
Alarm/Remote Control
Swimming Pool
I hereb certi ihaf I ins the elecf' al installafion described herein on fhe dafes stafed
Irrigation Boom �0„9�,.i„ Da �
Special Inspection e ' � `
in�l Dafe
Investigative Fee - 2/-0�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFIC�E USE OP'1�f This request voidyb�monfhs from validation dafe prinfed in this box.
I���I II III II III II III II III II III II III II III II III I II� /�
* 0 8 0 2 3 8 4�* ��0��
PLEASE PRINT OR TYPE ��
Requesf Date Rou fFin ins fion r uired? Yes
,g pec eq ❑ No Inspection Olher Than Rough-In: ❑ Ready Now Will Call
'�— Q � �You must call ihe inspector when ready) Date Ready:
I, ❑ licensed contractor ['� owner hereby request inspection of the above electrical work at:
Job Address (Sfreef, Box, or Route No.) City Zip Code
a �! er S��/t r� • 1 �n � g 3�
Section No. Township Name or N Range No. Fire No. County
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Occupanf Phone No.
I °v►�oi�y � W1; I�-rl' 7G �� �f��- �'76C
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Ical Conhactor �Company Name)
Q �.fi N�f
�g Address (Conhactor or Owner PerForming
or
Lic. No.
Phone No.
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