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REQUEST FOR ELECTRICAL INSPECTION ��;.:
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Minnesota State Board of Electricity � °`;
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �
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'* 0 3 8 7 7 3 1 3* Phone (612) 642-0800 �"�
ome Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Repair
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat emp. Service
"X" above the work covered by ihis request. Enter rema�ks in this space and on the back ot the white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL/� �
Sign/Outline Ltg. Xfmr. /�lN,-' /oY�-�l'
Alarm/Remote Control
Swimming Pool I hereby ceRify that I inspected the electrical installation described herein on the dates stated
Irrigation Boo Rough-In Date
Special Inspe
Fi�a� Dat � 2 /— �i'C�
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
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OFFICE USE ONLY This request wid 18 months from validation date printed in this box.
387-731 �
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PLEASE PRINT OR TYPE
Re st at Rough-in inspection required? ❑ Yes No Inspection Other Than� ug -In: Ready Now ❑ Will Call
(You must call the inspector when ready) Date Ready; /
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Jo��$ Street, 89 �te o.) � City �� � Z�p ���
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Section No. Township Name or No. Range No. Fire No. County
OccuPant _ V D / � Phorie No. � � � / / �
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Power Supplier Address
Electric ntractor (Company Name) Contractor License No. Master Lic. No. (Plant Elect. Ony)
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Mailir�Ad �ss�ntractor or O n�rfofming Installat�� �
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Auth rized gnature ( tractor or Owner Performi Installation) � �� Phone No
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EB-00001A-11 8/95 STATE RD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY