P - 82447�Q,L=228 �
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REGIUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 5510
Phone(612)642-0800
Home Duplex Apt. Bldg. Other: New
Commercial Industrial Farm Remod
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other: �/ �
Dryer Range Elec. Heat Temp. Service �jj' j/
"X" above the work covered by this request. Enter remarks in this space and on the ack of ihe white copy
Calculate Inspeciion Fee - This Inspection Request will not be accepted withouf the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders
Mobile Home Park Stall 0 to 200 Amps " 0 to 1 �
Street ltg./Traffic Sig. Above 200 Am s ve i
Transformer/Generator INSPECTOR'S USE ONLV TOT,
Sign/Outline Ltg. Xfmr.
Alarm/Remofe Confrol
Swimming Pool
I herebvi certifv thaf I insoecfed the eleclrical insmllaKon described herein on the dafe
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Fee
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Special Inspec�dr(•7 �.�
Investigative Fee F��� ���0�-� �
THIS INSTALLATION MAY BE ORDERED DISCO ED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validafion dafe prinfed in this box.
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PLEASE PRINT OR TYPE
Request Date Rou h-in ins Non r uired? ❑ Yes
/O �_ i ��/n g pec eq ❑ No Inspection Other Than RougMn: ❑ Ready Now �Nill Call
y ;���'�r � �You musf call the inspecfor when ready) Date Ready:
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I, ❑ iicensed contractor �wner hereby request inspection of the above electrical work at:
Job Address (Shcet, Box, or Roule No.) City Zip Code
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Section No. Township Name or No. RanAe No. Fire No. Coun A
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Power Supplier� �
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Elechical Contractor (Company Name)
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Mailing Address (Conhacror or Owner PerFormirg
Authorized Signature (C asjp r Perfo
Ph��� ������/�
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License No. Master Lic. No. IPlant Elect. Onlvl
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY