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Home � � Duplex
Gommercial Industrial
"X" above ihe work covered by
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Calculate Inspection Fee - This
Other
Mobile Home Park Stall
Sfreet Ltg./Traffic Sig.
Transformer/Generator
Sign/Outline Ltg. Xfmr.
Alarm/Remote Confrol
Swimming Pool
Irriqation Boom
REQUEST FOR ELECTRICAL INSPECTION —_
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800
Apt. Bidg. Other: New Addn
Farm Remod Re air
Water Hfr. Load Mgmt. Other:
Elec. Heat Temp. Service
is request Enter remorks in this space and on the back of the white copy only.
�il/1 C'O��7lOh/� �j � ��7��
ispection Request will noi be accepted without the correct fee:
Fee # Service Entrance Size Fee # Circuits/Feeders Fee
0 to 200 Amps 0 to 100 Amps 8�'
Above 200 Amps Above 100 Amps
INSPECTOR'S USE ONLY TOTA�� t��
✓
I
fhe elechical insfallafion described herein on ihe dafes sfafed
Investigative Fee ���� --`�=--- --- I D�_ �c'� r- l'
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This request void 18 months from validation dafe printed in this box.
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* O 4 6 8 O 8 D 7* PLEASE PRINT OR TYPE
Requesf Dafe Rou h-in ins fion r uved2 pecf' ug dy ❑ Will Call
! g pec eq ' ❑ Yes No Ins ion Other Than Ro Mn: Rea Now
`f '�J •� (`fou must call fhe inspector when ready) Date Ready:
I, licensed contractor ❑ owner hereby request inspection of the above elecfrical work at:
Job Addren �Shcet, Box, « Route No.) C�y Z� ��
G 2 �� /�icf �/�'F!e ,�i��v� �2/dt-� P
Secfion No. Township Name or No. Range No. Fire No. Couny .
Occupant
��r C�
Electricol ConhacA�r (Comp
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Maili�g u (Conhacfo
2 2 /?i�
or Owner Performing Installafic
�o�-� �'�Ll.��JE
Phone No.
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Address
Confracfor license No.
C.Qoos o�'
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,y%/�7�i ��v /
Lic. No. �Plant Elect.
or � r rtormuig I Ilah 5 i�� Phone No. �
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S ATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY