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REQUEST FOR ELECTRICAL INSPECTION ���.
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
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Phone (612) 642-0800
. O�ther: n� r ,�.� New Addn
I Industrial Farm i F�'� ���- �.-t� ` Remod �
Htg. Equip. Water Hh. load Mgmt. Other:
Range Elec. Heot Temp. Service
work covered by ihis request. Enter remarks in this space and on the back of the white copy only.
Calculate Inspection Fee - This Inspection Requesi will not be accepfed without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 00 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Outline Ltg. Xfmr. �"� • ��
Alarm/Remote Control
Swimming Pool
1 hereb certi thaf I ins fhe electrical insfallation described herein on the dates stafed
Irriaation Boomw w. .. ., .., R�,��� oore
� Investigative Fee � � �-----°� �.Z -LC3--=- I 0'/! ^/ l
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 monfhs from validation date prinfed in fhis box.
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* � 4 9 L � 7 5 8* PLEASE PRINT OR TYPE
Request Date Rough-in inspection required? ❑ Yes �y No Inspecfion Other Than Rough-In: eady Now ❑ Will Call
,-. ,� .-�-(, �You must call the inspector when reaoy� Date Ready:
I, �licensed contractor ❑ owner hereby request inspection of the above elecfrical work at:
Job Address (Sfreef, Box, o� Route No.J City Zip Code
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Section No. Township Name or No. Range . Fire No. Cou ^
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Confracfor
Mailing AdHress (Conhactor or Owner
�-�I�tG1 ��-1-,�;
or
Conhactor License
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Installafion, 2 5� p 5
:OPY - SEE INSTRUCTIONS ON
Phone No.
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� ' Phone No.
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F YELLOW COPY