P - 82322�,��36-030 �
REQUEST FOR ELECTRICAL INSPECTION �
Minnesota State Board of Electricity �'
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 �`i
(651) 642-0800 www.electricity.state.mn.us "'
"X" above the work covered by this reques►. Enter remarks in this space
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Calculate Inspection Fee - This Inspection Request will not be
Other Installations Fee # Service Enfrance Size Fee
Mobile Home Park Stall 0 to 200 Amps
Street Ltg. / Traffic Sig. Above 200 Amps
Transformer/Generator INSPECTOR'S USE ONLY
Sign / Outline Ltg. Xfmr.
Alarm/Remote Conhol
Swimmin Pool
copy only.
�pted without the correct fee:
# Circuits / Feeders Fee
0 to 100 Amps
Above 100 Amps
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g I hereb certi that I ins eleclrical insfallafion described herein on fhe dates stated:
Irrigation Bo Rough-In Da � /�
Ca
Special Insp � ` � ��
Final D �
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This requsst void 18 months from validation dafe printed in this box.
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PLEASE PRINT OR TYPE
Requesf afe Rough-in inspection requiredB Yes ❑ No Inspecfion Olher Than Rough-In: ❑ Ready Now Will Call
1�1 b Q You must call the�inspector when ready Date Ready: �
I,�licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sheet, Box, or Route No.) City � Zip Code
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Section No. Township Name or No. Range No. Fire No. Cou
Occupant Phone No.
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Power Supplier Address
2828��
Elechical Con}ractor / Company Name ` Contracfor License No. Masfer Lic. No. �Planf Elecf. Only�
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Mailing Address �Conhactor, Company or Owner Performing Insfallation� �
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Authori ignafure (Confwacfor, Company or Own Performing Insfallafion� Phone Number
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STATE BOARD COPY
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SEE INSTRUCTIONS ON BACK OF YELLOW CO