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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 "�'
. Other: New Addn
Industrial Farm
Htg. Equip. Water Htr. Load Mgmt. Other:
Rang I Elec. Heat Temp. Service
�overed by this request. Enter remarks in this space and on
Remod
of the white copy
Calculate Inspection Fee - This Inspection Request will not be accepied withouf the correct fee:
Other Fee # Service Entrance Size Fee # Circuits
Mobile Home Park Stall 0 to 200 Amps to 100 A
Street Ltg./Traffic Sig. Above 200 Amps Above 100
Transformer/Gener INSPECTOR'S USE ONLY
Siqn/Oudine Ltq. X r � �o�'Y�"� �'�f"
thaf I inspc�c;ted fhe elecirical insiallation described herein on the dates
, d E1 1 Date .
Fee
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Special lnspectio �"'� �
Final - 9�� ��C'�Q�
Investigative Fee / ��
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
�^ OFFICE USE ONLY This request void 18 months from validafion dafe prinfed in this box.
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�K � 5 1 7 7 4 6 4* PLEASE PRINT OR TYPE f, �
Request Day �_� Rough-in inspection required? Yes ❑ No Inspection Other Than Rough-In: ❑ Ready Now Will Call
�You must call ihe inspector when ready) Date Ready:
I, �licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address �Street, Box, or Route No.� �� � �1y � I� f� Zip Code
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Seclion No. Township Name or No. Range No. Fire No. Couny
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Oc,cy�° nf ' / Phone No.
C.!l%rr 1��'P t�Z�►�YI_ �� i�1 �c� E? r-� .�'%% ��3 �
Moiling Address
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EB 00001 A-11
(Company Name)
16901 Xylite St. NE
Confractor License No. Master
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Phone No.
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