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"X" above the
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REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-�128, St. Paul, MN 55104 �:
Phone (612) 642-0800 � ;_ `' j '
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Apt. Bldg. Other: New Addn
Farm Remod Reaair
Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
request. Enter remarks in this space and on the back <
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copy
Calculate Inspection Fee - This Inspection Request will not be accepied without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps ,f, 'oa
Street Ltg./Trar`fic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY T TA�j
Sign/Outline Ltg. Xfmr. �G�J' ��
Alarm/Remote Control
Swimming Pool
I hereb cerfi ihat I ins fed the elec}rical installafion described herein on ihe dafes stated
Irrigation Boom Rough-In pa�
$pecial Inspect
Investigative Fee �� y�--------- �— �— � �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED_ WITHIN 18 MONTHS.
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OFFICE USE ONLY This requesf void 18 months 6om validation dafe printed in this box.
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* � 4 5 2 1 8 5 2�K PLEASE PRINT OR TYPE
Requesf Date Rough-in inspecfion required? ❑ Yes No Ins ection Olher Than Rou Mn:
� P g ❑ Ready Now�Will Call
,, ��-� �^ �� �You must call the inspecfor when ready) Date Ready:
I, �'licensed contractor ❑ owner hereby request inspection of the above elecfrical work at:
Job Address �Sheef, Box, or RouTe No.) City Zip Code
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Section No. Township Name or No. Range No. Fire No. C unH _
Power Supplier
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Name�
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(Conhactor or Owner PerForming Installafion)
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or
Phone No.
Conkactor License No.
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TIONS ON BACK OF YELLOW
Lic. No. (Plant Elecf.
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hone No.
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