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REC�UEST FOR ELECTRICAL INSPECTION ��"��
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Minnesota State Board of Electriciry
1821 Universiry Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993 �� -�.
(651) 642-0800 www.electricity.state.mn.us
IRange I I Elec. Heat I I Temp. Service I
work covered by this request. Enter remarks in this space and on the back of the white copy
Repair
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Calculate Inspection Fee - This Inspe�on�eq e�l`�iof be accepted without the correct fee:
Ofher Installations Fee # Service Enirance Size Fee # Circuits / Feeders Fee
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
Sign / Outl . f ��� 3e � �
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Swimming Pool
I hereb certi that I ins ected the electrical installation described herein on the dates stated:
Irrigation Boom Rough-In �°�e
Special Inspection
Final �e �_ �.
Investigative Fee
ru�c �4�cTn� �.eT�f_1nt �neV .RF f1L711FRFROIC�`ANNIFf`SFJ'f.IF NOLr.O.slP.l FTFI'] 1NITHIN 1R MONTHS. _..-_
OFFICE USE ONLY This �equesf void 18 months from validation date printed in fhis box.
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PLEASE PRINT OR TYPE
Request Date Rough-in inspection required? ❑ Yes �lo Inspeclion Other Than Rough-In: �'i�ady Now � Will Call
,� ` O,.. Q a You must call the inspector when ready � Date Ready: �
1, �censed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address (Street, Box, or Route No.) City Zip Code
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Section No. Township Name or No. Range No. Fire No. Coun
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Occu anf Phone No.
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Power Supplier Address
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Electrical Contra or / Company Name Contractor License No. Master Lic. No. �Plant Elect. Only�
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Mailing Address (Conhactor, Company or Owner Performing Installation�
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Auth ized Sig r ontra r, C pa �r O ne erfor ' Phone Number
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EB-00001 -1 /1999 STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY