P - 82122U-��`36�472 �i
REQUEST FOR ELECTRICAL INSPECTION �
Minnesota State Board of Electricity 3
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 ��`
(651) 642-0800 www.electricity.stafe.mn.us
Calculate Inspe
Other Installations
Mobile Home Park Stall
Sheet Ltg. / Traffic Sig.
Tra nsformer/Generator
Sign / Outline Ltg. Xfmr
Alarm/Remote Control
Swimming Pool ">
Fee ubi's Inspection Request will not be accepted withou► the correct fee:
# Service Enhance Size Fee # Circuih / Feeders Fee
0 to 200 Amps 0 to 100 Amps
Above 200 Amps Above 100 Amps
INSPECTOR'S USE ONLY TOTAL
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t I hereb certi that I ins ted fhe electrical installation described herein on the dates stated:
I�rigation Boom Rough-In Da}e
Special Inspection
Date
Investigative Fee �° ^Z.'L—""°3
� THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OPFICE USE ONLY This request void 18 months from validation date prinied in this box.
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PLEASE PRINT R TYPE
Request fe Rough-in inspecfion required? ❑ Yes ❑ No Inspection Ofher Than RougMn: Ready Now � Will Call
..� '� You must call fhe inspecfor when ready Date Ready:
I, licensed contractor ❑ company ❑ owner hereby request inspection of the above electrica4 work at:
Job Address (Shcet, Box, or Roure No.) Ci Zip Cod�e���
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� Section No. Townshio Name or No. Ranae No. Fire o. CounH .
Occupant
Power
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SignaNre
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�any Name
E ELECTRfC, It�C.
MN 55433 ��
xfo ny or Owner Performi�
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STATE
No.
0
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SEE INSTRUCTIONS ON BACK OF YELLOW COPY