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REQUEST FOR ELECTRICAL INSPECTION =
Minnesota State Board of Electricity
7821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993
(651) 642-0800 www.electricity.state.mn.us `��'
Home Duplex Apt.8ldg. Other: New Addn
Commercial Intlustrial Farm Remod Repair
Air Condifioner 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 wi�hou► the correct fee:
Other Installations Fee # Service Enirance 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 ...V
Sign / Outline Ltg. Xfmr. S
Alarm/Remote Control � 1`j Q �:'}
Swimming Pool i v Fr
I hereb ceAi thot I ins ted the electrical insfallation described herein on the dates stoted:
Irrigation Boom Rough-In Date
Special Inspection
Final Date
Investigative Fee .---��.��i""" — 2`� —'e2
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This req�est void 18 moniFis kom validation dote printed in this box.
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PLEASE PRINT OR TYPE
Request Date . Rough-in inspection required? ❑ Yes ❑ No Inspection Ofher Than Rough-In: Ready Now � Will Call
��� I� ,_ Q� � You musf call fhe inspector when ready Dafe Ready:
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1, licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
1ob Address (Street, Box, or Route No.) Ciy c (' Zip Code
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1 Sectio� No. I Townshio Name or No.
�Con}ractor, Company or Owner
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iture IContractor, Company or O�
Range No. Fire No. Coun
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Phone No.
Address
Contractor Licanse No. Master Lic. No.
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Insfallafion) �
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STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPV