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Home Duplex
Commercial Industrial
Air Cond. tp. Equi
REf�UEST FOR ELECTRICAL INSPECTION =_
Minnesota State Board of Electriciry
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
Apt. Bldg. Other: New Addn
Farm Remod Re air
Water Htr. Load Mgmt. Other:
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 only.
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Calculate Inspection Fee - This Inspection Requesi will not be accepted without the correc► fee:
Other Fee # Service Entrance ize Fee # Circuits/Feeders Fee
Mobile Home Park Stall t mps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL �j
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Sign/Outline Ltg. Xfmr. j/�� ~'
Alarm/Remote Control
Swimming Pool 1 —� ��
I heieb certi fhat I ins ed !he elechical insfallation described he� fhe dates,Aa
Irrigation Boom RougMn � �a�
$pecial Inspectio � ti*�,•r L, _�r—
Final ^ �a '
Investigative Fee ,-C�{' --- — '-���'
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 mo�ths from validation date prinfed in this box.
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* � S 5 8 2�a �=' �� PLEASE PRINT OR TYPE
Requesf Date Rough-irt inspection required? es ❑ No �nspection Other Than Rough-In: ❑ Reody Now ill Call
��L �� � (You must call the inspector when ready) Date Ready:
I, ' ensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address �S}reet, Box, or Route No.) t . � Cif�, , ; _ Zip Code
Section No. I Township Name or
Confrqctor (Company Name)
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dress Cont actor or Owner
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�d Signatur� �Conhacfor or O
Range No. Fire No. County �
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Pho�e No. f�
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Address �
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Co actor License No.
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