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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 " '
Other: New Addn
Farm Remod
Water Htr. Load Mgmt. Other:
Elec. Heat Temp. $ervice
request. Enter remarks in this space and on the back of the white copy only.
Calculate Inspection Fee - This Inspection Request will not be accepied 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
Sfreet Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR•s use oN�r TOTAL„ �
$ign/Outline Ltg. Xfmr. "—���'
Alarm/Remote Confrol ^ � �j..� �"'�
f �/b ,.
Swimming Pool %
I hereb certi thaf I ins fhe electrical installation described herein on the dates sMfed
Irrigation B t�` RougMn Date
Special Ins o �` 6
Investigative Fee Fi�wl
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THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validation date printed in this box.
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PLEASE PRINT OR TYPE
Requesf Dafe Rough-in inspecfion required? Yes ❑ No Inspecfion Other Than Rough-In: ❑ Ready Now ill Call
/Q '�- 9 9 (You must call Ihe inspecfor when ready) Date Ready:
I, licensed confractor ❑ owner hereby request inspection of the above electrica► work at:
Job Address (Sheet, Box, or RoWe No.� iy ' Zip Code
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SecFion o. Township Name or No. Ranqe No. No. un �
Occupant
Power Supplier
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Elechical Conhaclor (Compa�ry Name) ,
M� Addreu �Con acfor or O er Performing
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Aut o� rized $ignature �Conhacfor or Owner Perfon
Phone No.
Contracfor License
L�/�D ��
COPY - SEE INSTRUCTIONS ON BACK OF
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