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Home Duplex Apt. B
Commercial Industrial Farm
REGIUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) . . 080
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Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Ran e Elec. Heat Tem . Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the
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Colculate Inspection Fee - This Inspection Request will not be accepfed without the correct fee:
Olher Fee # $ervice E�trance 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'SUSEON�Y ,d '' TOT L
Sign/Outline Ltg. Xfmr. �� Y���' � r
Alarm/Remote Control
Swimmin Pool �` ^7
9 I hereb ceAi }hat I ins ecfed ihe eledrical installation described�on }he tes s�fed� /
Irrigation Boom Rough-In ��e
$pecial Inspection � — Z �p
Final � �
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 ONTHS.
2 9 9- 4 0 4� OFFICE USE ONLY This request void 18 months from validation date printed in this box
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PLEASE PRINT OR TYPE
Re t Date Rough-in inspedion required2 ❑ Yes � No Inspedion Other Than Rough-In: ❑ Ready Now � Will Call
� 2Z ��"" (You must call the inspedor when ready) Date Ready:
I, ❑ licensed contractor owner hereby request inspection of the above electrical work at:
Job Address (Streef, Box, or Roufe No.) City Zip Code
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Sedion No. Township Name or No. Range No. Fire No. � County
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Powe�pplie� Address
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Elecinwl Contracior (Company Name) Contrador License No. Master Lic. Na. (Plant Elecf. Only)
Mailing Address (Conirador o Owner erforming Installation)
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Aut ' ed Signatu �Confr or o�wner Performing Installafion) � Phone No.
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:B-00001 -.10 6/95 STATE BOARD COPY - SEE INSTRUCTIONS ON BACKOF YELLOW COPY