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R�QUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity a
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �
Phone (612) 642-0800 "°�'
Apt. Bldg. Other: �P(q�� ti9�, �u,S� � New Addn
Farm �'Icu �.9� o�►.� ..�,.. Ai1�sr. Remod Repair
Htg. Equip. Water Htr. Load Mgmt" Other:
Range E{ec. Heat Temp. Service
covered by this request. Enter remarks in this space and on the back of Ihe white copy
296� 3 ��
Calculate Inspeciion Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance ize Fee # Circuits/Feeders Fee
Mobile Home Park Stall to 00 Amps 0 to 100 Amps
Street L./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Oudine Ltg. Xfmr. , •
Alarm/Remote ControT � • Q
Swimming Pool
I hereb certi fhat I ins ted the elechicol installallo� dexribed herein on fhe dales staled
Irrigation Boom Rougffln `—�
Special Inspection
Final �
Investigative Fee �-
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WfTHIN 1 MONTNS.
OFFlCE USE ONLY This request wid 18 months kom validafion date printed in fhis box.
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* 0 8 0 2 3 4 2�, �c ��
PLEASE PRINT OR TYPE �
Request Date Rough-in inspection required? ❑ Yes ❑ No Inspecfion Ofher Than Rough-In: ❑ Ready Now � Will Call
(You must call the inspector when reody) Date Ready:
I, ❑ licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Addreu �Street, Box, or Roule No.) Ciy Zip Code
lD`� �� C.c.�K %��. 6�-t,o��y s�'y��
Secfion No. Township Name or No. RanAe No. Fire No. Couny
Occupant
Cax*r�o S�, z.
Power Supplier
Name)
Addreu �Conhacbr or Owner
Phone No.
- �rsf'
Masfer
STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY