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REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electric+ty
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
New
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ommercial Industrial Farm Remod Re
Air C 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 cnly.
In C � �'-�
Calculate lnspeciion Fee - This Inspecfion Reque ill 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
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S use oN�v TOTAL ,��y
Sign/Oudine Ltg. Xfmr. �J
Alarm/Remote Control
Swimming Pooi I herebv cerfifv thot I insoected the elecirical installation described herein on the date���
THIS INSTALLATION MAY BE ORDERED
_
I lill !I III I! II! II III II III II III�I II! ��I I�II
* 0 8 0 1 4 3 7 5*
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DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTFIS.
OFFlCE USE ONLY This requeat void 1 S months from validafion dafe printed in this box.
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PLEASE PRINT OR TYPE
Requesf fe Q Rough-in inspecfion required2 ❑ Yes ❑ No Inspeciion Other Than RougMn: Ready Now 0 Will Call
��� '! p (You musT call the inspecfor when ready� Dafe Ready:
I,�censed contractor ❑ owner hereby request inspection of the above electrical work at:
1 Addreu (St�et, Box, or Route No� A � � ` _ Ci _ n � Zip Code
or
0
Power SuppT �� � `� �
Elechical Conhacror (Company Name�
1EPENDABLE ELECTRiC. INC.
h�il�Ac�r��o ' Insk
;eon Rapids, MN 55433
Authorized Signature �ConhacTor or Owner P mg
No. � Fire
Phone�� � ��
7 J,
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/ �.�..�.J�l X/ i.�y V I—%S �—`SZ� '�!�
STATE BQ06 Y- SEE INSTRUCTIONS ON BACK OF YELLO