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"X" above
REGIUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �
Phone (612) 642- ' '
Apt. Bldg. Other/ � S', New Addn
Farm / ' �� Remod Re air
ip. Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
�y 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 withouf fhe correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders
Mobile Home Pork Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTO�R'S klS�E ONLY TOTAL�
Sign/Outline Ltg. Xfmr. s-�O{ 'E /�u.yr U�
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Fee
.�d
Swimming P ��(��( _�
I hereb certi that I ins fhe electrical i lafion described r th da s
Irrigation B Ro„g�l„
Special Inspection � ��
Firwl
Investigative Fee -�.� • �
�THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This requesf wid 18 months 6om validation date prinfed in this box.
I IIII II III II III II III II III II II�I III II III I IIII �i W
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* 0 8 0 2 2 2 5 3* ��.��
PLEASE PRINT OR TYPE
Request Date /y/�-� Rough-in inspecfion required? es ❑ No Inspecfion O�er Thon RougMn: eady Now 0 Will Call
��� �VV ou must call fhe inspeclor n r � Dofe Ready:
I, ❑ licensed contracto owner hereby request inspection of the above elech�ical work at:
lob Address Skeet, B or o.) City Zip Code
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Secfion No.
OccupanT
' 2r/D LD
/�
S
ny Name�
j��
or Owner Performing Insfallation)
icro/ or er PerForming Installc
Fire No. Covnly ( /� _O�
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Phone No.
Cs �a��/ �. �/
Conhacfor license No. Master Lic. No.
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STA BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY