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REQUEST 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. tsldg. Other: New
Commercial Industrial Farm
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
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of the white copy only.
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
Street Ltg./Tra`rfic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY T�� `�
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
$wimming Pool
I hereb certi ihat I ins ted�the eleckical installation described herein on the dates stafed
Irrigation Boom Roo9h-io Da�e ^ 2� �.
Special Inspectio � Dafe
Investigative fee ����� �'' � �--`--- '� –� � — C' �
THIS INSTALLATION MAY BE ORDERED QISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
� OFFICE USE ONLY This requesf void 18 monfhs from validafion dafe prinied in fhis box.
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Requesf Dafe Rou h-in ins cfion r uired? Yes
g pe eq ❑ No Inspecfion Ofher Than Rough-In: ❑ Ready Now Will Call
�.� ��� �% �You must call the inspecfor when ready) Dafe Ready:
I, � licensed contractor ❑ owner hereby request inspection of the above electrical work at:
1ob Address (Sheet, Box, or Route No.) City Zip Code
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Section No. Township Name or No. Range No. Fire No. County
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Power Supplier
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Mailing Address (Contractor or Owner Performing Insfallation)
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Phone No.
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Iress
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Conhactor License No. Masfer Lic. No. (Plant Elecf.
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Authorized Signatu�re IC`onfracforg �Owner�rfgrming Insfallation� n Phone No.
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IB-0000 A-1 1 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY