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REQUEST FOR ELECTRICAL INSPECTION F"E
Minnesota State Board of Electricity `�
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993 ��.
{651) 642-0800 www.electricity.state.mn.us '�
OFher: New Addn
Remod Repair
Dryer I I Range I I Elec. Heat I I Temp. Service I
"X" above ihe work covered by this request. Enter remarks in ihis space and on the back of ihe white copy only.
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Calcula e Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Installations Fee # Service Enkance Size Fee # Circuits / Feeders Fea
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg. / Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL 7r Jr, -a
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Poo�
Irripation Boom
�
insfalla}ion
oare
� Investigative Fee � � �/ �"� � )�''��9U �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 months (rom va�idation daie printed in this box.
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0
� PLEASE PRINT OR TYPE
Requesf Dafe Rough-in inspeclion required$ Yes No Inspection Ofher Than Rough-In: �Ready Now 0 Will Call
—� O You must call the inspector when ready Date Ready: ��
I, �licensed contractor ❑ compa�y ❑ owner hereby request inspection of the above electricol work at:
Job Address (Strcet, Box, or Route No.� � Ciy �; �� Zip Code
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Sec No. ownship Name or No. Range No. Fire o. County
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Ocwoant Phone Na �
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Power Supplier Address
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Electrical Conhactor / Company Name Contracfor License No.
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Mailing Address �Conkacfor, Company or Owner Performing Installafion�
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Authorized Signature (Conhactor, Company or Owner Performing Installaf n)
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Masfer Lic. No.
Phone