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RE(�UEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
Apt. Bldg. Other: New
Farm Remod
Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
request. Enfer remarks in this space and on the back of the white copy
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Calculafe Inspection Fee - This Inspection Request will not be accepted wfthout the correct fee:
Other Fee # Service Entrance Size F # Circuits/Feeders e
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 iNSaecTOR�s use oN�v TOTAL
Sign/Outline Ltg. Xfmr. ( f�-/—��-�8�g �
Alarm/Remote Control �rN- � � � 9 �� ��
Swimming Pool
I hereb certi thaf I ins the electrical insfallafion described herein on fhe dafes stafed
Irrigation Boom RougMn Dafe
Special Inspectio
Investigative Fee � � � — —C�
THIS INSTALLATION MAY BE ORDERED ECTED IF NOT COMPLETED WITHIN 18 MONTHS.
_ OFFICE U� ONLY This roquest void 18 mo�ths from validation date prinfed in ihis box.
� ��I� �f ��I �� ��I �� ��� �� �I �� ��� II � � � � � � �� s o � � � �as�
* 0 6 8 9 0 3 9 6*
PLEASE PRINT OR TYPE
Requesf Dafe Rough-in inspecfion required?� ❑ Yes
�—��'^� ❑ No Inspecfion Ofher Than Roughan: ❑ Ready Now ❑�II Call
�� (You musf call the inspedor when ready) Date Ready:
L
I,�] licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Add� (Sheer, Box, w Rou�e No.� � Ciry� � Zi� e �
r. �(' J �7
�
Secfion No. Townshio N e or No. Ranae No. Fire No. Coun /
c�. r� I�!
Phone No.
Power Sup lier Address �
$ d ClI�'���
Electrical Conha r(Company Name� Conhacfor License No. Masfer Lic. No. (Planf EI
^v � �
Mailing A ress (Conh or er rforming IlaKon)
� � � h Ss�
Authori Si ature �Conha or Ow i ns la' n) ,� j� `� Phone No.
Lst � 1j�1
E����� � 8� STATE BOARD COPY - SEE INSTRUCTIONS O BACK OF YELLOW COPY