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Home Duplex
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800
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 this request. Enter remarks in this space and on the back of the white
Wir�. as �i�e�p �o�ce�
Calculate Inspection Fee - This Inspection equest will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeden
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 A
Transformer/Generator INSPECTOR'S USE ONLY TOT
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
Irrigation Boom
Special Inspectio
I hereby certify that I inspected the
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copy only.
Fee
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herein on the dates stated
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Investigative Fee -----• -- —l:s—/
THiS INSTALLATION MAY BE OFiDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONT .
OFFICE USE ONLY This requesf void 18 months 6om validafion dafe prinfed in fhis box.
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Request Date Rou h-in ins ecfion r uired?
g p eq ❑ Yes No Inspecfion Ofher Than Rough-In: ❑ Ready Now Will Call
,��� �q (You must cal) the inspector when ready) Date Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
lob Addreu (Streef, Box, or Roufe No.) City Zip Code
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SeMion No. Township Name or No. Range No. Firc No. Co nty
J Contractor
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Address ICc
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Address
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ctor�or Owner PerForming �nstallafjqn)
STATE BOARD
Phone No.
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