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REGIUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800
New
Commercial Industrial Farm Remod
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy on
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Calculate Inspection Fee - This Inspection Requesf will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders
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 INSPECTOR'S USE ONLY TOTAL ��
itline Ltg. Xfmr.
emote Control
ig Pool �
i Boom
InSpeCtiOf}� ..
that I ins ected the elechical installafion described herein on the da
Date
Fee
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� Investigative Fee �I V,i�i `� e� � � C1^ I��'`Y °
THIS INSTALLATION MAY BE ORDEREQ DISCONNECTED IF NOT COMP�ETEn.�euTHIN ia-�[�d=�� .
i OFFICE USE ONLY This request void 18 mo�ths from wlidation date printed in this box.
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* 0 6 5��8 7 0 6'� * �: � y�i 7 7
PLEASE PRINT OR TYPE
Request Da /�. Rough-in inspecfion required? ❑ Yes No Inspection Other Than Rough-In: ❑ Ready Now Will Call
��2� I�j� (You musf call the inspecror when ready) Date Ready:
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I, �licensed contractor ❑ owner hereby request inspection of the above electrical work at:
lob Address (Street, Box, or Route No.) Ciy Zip Code
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Secfion No. Township Name or No. Range No. Fire No. Coxnly A 9
Occupant �� � � ���
Power
ol Conhacfor (Company Name)
BLA{NE H7G. AJC ELECT•, �NG.
Address
Phone No.
5� L �
Conhacfor License No.
Lic. No.
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NS ON BACK OF YELLOW COPY