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REC�UEST FOR ELECTRICAL INSPECTION -.��..
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104 -
Phone (612) 642-0800
Apt. Bidg. Other. New Addn
Farm Remod Re air
Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
request. Enter remarks in this space and on the back of the white copy only.
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Calculafe 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
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL�c .�J,-Q
Sign/Oudine Ltg. Xfmr. �✓
Alarm/Remote Conhol
Swimming Pool I hereb certi thaf I ins the elecfrical installafion described herein on the dates sfated
Irrigation Boom Ro„y�.i„ Dar�
Special Inspech ( " �' _
_ Fi,wl �e
Investigative Fee � � -�
THIS INSTALLATION MAY BE ORDERED DIS CTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USF� ONLY This request void 18 monfhs from validafion daTe prinfed in fhis box.
I IIII II I�I I) �II I) II� II �I) �I (II II II) II III I IIII
�C� s� • �7s�
* � 4 L � 5 1 9 3�Ic PLEASE PRINT OR TYPE
Request Date Ro h-in ins fion r uired2 � ❑ Will Call
ug pec eq ❑ Yes No Inspection Other Than RougMn: Ready Now
`�— /� "� �7 �`/ou musf cali the inspecbr when ready� Dafe Ready:
I, �licensed contractor ❑ owner hereby request inspection of the above elechical work at:
Job Address (Sheet, Box, or Route No.) Ciy Zip Code
/(3 , �4c-c� G-��-�-v� �CYc� ��Sl�
Secfion No. Township Name or No. Ranqe No. Fire No. ouny �.
Occupant
�C�/l ��..�%�°%�
Eleciriml Conkacror (Company Name (` � `� , �, �..�
Ce.>r��l� �' L.'� `-'�' .
Mailing Addr s(Conkactor or Owner Performing lnsf�ation)
., .� c
fT�lJO/� �
Phone No.
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STATE BOARD CflPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY
(Plant Elecf. Only�