P - 81575�1�-941-2C8 0
Duplex � �Apt.
REQUEST FOR ELECTRICAL INSPECTION �
Minnesota State Board of Electricity �
1821 University Avenue Suite S-12$ Saint Paul, Minnesota 55104-2993 ���
(651) 642-0800 www.electricity.state.mn.us "�'
Air Condifioner Hfg. Equip. Water Htr. Load Mgmt. CJther:
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
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Calculate Inspection
Other Installatio�s Fee
Mobi�e Home Park Stall
Street Lt . / Traffic Sig.
Transformer/Generator
Sign / Oudine Ltg. Xfmr.
Alarm/Remote Control
Swimminq Pool
Fee - This Inspeciion Request will not be accepted without the correct fee:
# Service Enfrance Size Fee # Circuih / Feeders F
0 to 200 Amps 0 to 100 Amps
Above 200 Amps Above 100 Amps
INSPECTOR'S USE ONLY TOTAL
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I herebvi certifv thar I
described herein on the dates
Date
Date
Investigative Fee v
7HIS INSTALLATION MAY BE ORDERED DISCONN ED IF NOT COMPLETED WITH N 18 MONTHS.
� � � OFFICE USE ONLY This requesf void 18 monihs from valida' �te printed in this box.
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PLEASE PRINT OR TYPE
Request Date Rough-in inspection required?�� Yes ❑ No Inspection Other ihan RougMn: ❑ Ready Now ❑ Will Call
�O •� �j 'i Q'v You must call ihe inspecfor vlben re8dy Date Ready:
I, licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sfreet, Bo or Route� City Zip Code
S ,�.s �d/� s53
Section No. Township Name or No. Range No. Fire No. Counfy� �
Occupanty Phone No.
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Power Supplier
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Elechical Conhactor / Company Name
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Mailing Address �Contractor, Company or
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Authorized Signature (Contracror, Com�
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STATE BOARD COPY
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Master Lic. No. (Planf Elect. Unly)
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Phone N�u,mAber (��
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SEE INSTRUCTIONS ON BACK OF YELLOW COPY