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REC�UEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
Home Duplex Apt. Bldg. Other: New
Commercial Industrial Farm Remod
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by ihis request. Enter remarks in this space and on the back of the white copy
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Calculate Inspection Fee - This Inspection Request will not be accepted 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
Sfreet Lig./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTALs�
Sian/�ut�ine Lta. Xfmr. ��'�"
Alarm/Remote Confrol
Swimming Pool I here certi that I ins the elechical installation described herein on the dates
Irrigation Boom � � _ Ro�aMo Dare
Investigative Fee �' `� � � �.-.�.�f 7 d"
HIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
I�� II II) II III OFFICE USE ONLY This request void 18 m� from validation date printed in this box.
II III �I I� II �II II III II III I� (�V V
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PLEASE PRINT OR TYPE
Requesf Date Rou h-in ins on r uired?
p, g pecfi eq ❑ Yes No Inspection Other Than Roughan: Ready Now � Will Call
Gj �S� �O �`!ou must call the inspecfor when ready) Date Ready: 6- 3C —��
I, �licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address �Sheef, Box, or Roufe No.) City � Zip Code
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Section No. Township Name or No. Range No. Fire No. Couny
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Occupant Phone No.
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Power Supplier Address � .
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Elechical Conhacfor �Company Name) Conhaclor License No. Masler Lic. No. (Planf Elecf. Onl�
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Mailing Address �Conhaclor or Owner Performing Installation)
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Aufhorized Signature �Conhacfor or r Performing InsfallaKon� Phone No.
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B-00001 A-11 8/96 S E B RD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY