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Farm
REQUEST FOR ELECTRICAL INSPECTION �
Minnesota State Board of Electricity
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993 ���
(651) 642-0800 www.electricity.state.mn.us '� �
Repair
Air Conditioner Htg. Equip. Water Htr. Load Mgmt. � Other. I
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 only.
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Calculate Inspection Fee - This Inspection Request will not be accep► wi o�orrect fee:
Other Installations Fee # Service Enhance Size Fee # Circuits / Feeders Fee
Mobile Home Park Stall ► 0 to 200 Amps '�'1. � 0 to 100 Amps
Street Ltg. / Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOT�L �.
Sign / Oudine Ltg. Xfmr. L�Z� �,�J„ B�_ .'� � i.J�
Alarm/Remote Control �v-����
Swimming Poof
I hereb certi that I ins fed fhe elechical installation described herein on the dafes sfated:
Irrigation Boom RouyM� Dare
Speciallnspect ! ' ti,
Investigative Fee ����I ��re �- 2.'3 cg B
THIS INSTALLATION MAY BE ORDERED DISC TED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validation date printed in this box.
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PLEASE PRINT OR TYPE
Requesf Dafe Rough-in inspection required$ ❑ Yes ��o Inspecfion Olher Than Rough-In:�ady Now 0 Will Cail
r, '� �(�� You must call ihe inspecfor when ready Date Ready:
I,`�7licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Addreu (Sheef, 8ox, or Roufe No.) City Zip Code
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Secfion No. Townshio Name or No. Rana No. Fire No. Cou
Phone No.
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Power Supplier V Address
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Elechica) Contracror / Company Name Conhocfor License No. Mastar Lic. No. �Plant
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Mailing Address (Confractor, Company or Owner Performing Installafion)
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Phone Number
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�NS ON BACK OF YELLOW COI