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Commercial Industrial Farm
REGIUEST FOR ELECTRICAL INSPECTf'f�N +�- :�: �
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800
Other: New Addn
Remod Repair
Air Cond. Htg. E uip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service � �Q� C'r`✓�Ti '�,f�n�
"X" above ►he work covered by th �s request. Enter remarks in ihis s ace and on the back of the white copy only.
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Cakulate Inspection Fee - This Inspection Request will not be accepied without the correci fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 00 Amps 0 to 1 QO Amps
Sfreet Ltg./Traffic Sig. Above 200__Am s Above 100 Amps
Transformer/Generator INSPECTOR'S usE oN�r TOT � O(
�ign/Outline Lig. Xfmr. �
Alarm/Remote Control
I here certi that I ins ihe elechical installafion dexribed herein on the dates staled
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� Investigative Fee � -� � _ � -- j--� ���-Y'�
THIS INSTALLATION MAY BE ORDERED DISCONNECTEb IF NOT COMPLETED WITHIN 18 MONTHS.
-- - � � OFFICE USE ONLY This req�est void 18 months 6om validafion dale printed in ihis bo�
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* 0 4 2 9 0 5 I+ Ia �K PLEASE PRINT OR TYPE
Re9'�est �°te Rou fFin ins ion r uired? Yes
g pecF eq ❑ No Inspection Olher Than Rough-In: ❑ Ready No Will Cal
// / LO � 9�j> (You must call the inspecror when ready) Date Ready:
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I, �licensed contractor ❑ owner hereby request inspection of the above electrical work at:
lob Addreu (Sheei, Box, or Ro No.) � � Ciy Zip Code
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Section No. Township Name or No.
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Power Sup���
Eleclricnl Conhactor (Comparry Name)
Address (Conhactor or er Peffi
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!eoLSiprwlure IConhacbr or Owner
Ranpe No.
Phone No.
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� Confracror License No.
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STATE BOARD COPY - SEE INSTRU S ON
Master Lic. No. �Plant E
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YELLOW COPY