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REQUEST FOR ELECTRICAL INSPECTION
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
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Diyer Range Elec. Heat Temp. Service
"X" above the work covered by this request. En►er 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 withouf the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY O1T�AL
Sign/Outline Ltg. Xfmr. .�C.' • �
Alarm/Remote Control
Swimming Pool
I hereb certi ihaf 1 ins the elechical insfallafion described herein on the dates stated
Irrigation Boom • Rougl.ln �--- pare 2_� f�/
Special Inspectio • � °
final pa
Investigative Fee - �' � j - 9�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void I S monihs from validafion date printed in this box.
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Request Dafe Rough-in inspection required2 ❑ Yes
❑ No Inspection 01her Than RougMn: ❑ Ready Now ❑ Will Call
�' ��. �-° � (You must call the inspecfor when ready� Dafe Ready:
I, � licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sfreet, Box, or Route No.� City t Zip Code
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Secfion No. Township Name or No. � Range No. Fire No. County
Occupant �
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Power Supplier Address
Elechical�Conhactor (Company Name)
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Mailing Addreu (Conh or or Owner PerFo ming Insfa�lation)
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Auth riz ignature �Conh or or r Performing Installafion)
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STATE BOARD`COPY - SEE
Phone No.
Conhactor License No.
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