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Home Duplex
Commercial Industrial
Air Cond. Htg. Equi
Dryer Range
"X" above the work covered b
RE(�UEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) �2- 0
Apt. Bldg. Other: � New
Farm � Remod
Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
request. En►er remarks in this space and on the back of the white copy
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feed�
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100
Transformer/Generator INSPECTOR�S USE ONLY TC
Sign/Outline Ltg ,J�e � CA�%- �
Alarm/Remote �lt�'r``''1` H� �y�� � au..
Swimming Pool
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Fee
TAL�/CT
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I hereb certi fhat I ins ected fhe electrical installation dexribed herein on the dc
Irri9afion Boom RougMn Dare
Investigative Fee - �` / i�cs( �"'� ^ 'L%s' •. d �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN MONTHS. �
OFFlCE USE ONLY This request void�monfhs from validation daM prinfed in fhis box.
I I�II II II) II III II III II (II II III II II) II II) II III I IIII �� �� '
* 0 8 0 2 4 0 0 2* � ),�
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PLEASE PRINT OR TYPE
Request Date Rough-in inspection required? ❑ Yes ❑ No Inspecfion O�er Than RougMn: ❑ Ready Now ❑ Will Call
,� �You musf call the inspector when ready) Date Ready:
I, ❑ licensed contractor � owner hereby request inspection of the above electrical work at:
lob Addreu �Sheef, Box, or Route No.) City Zip Code
. � � � . �
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Section No. Township Name or No. Range No.
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Occupant
Power Supplier Address
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Elechical C hacfor (Company Name�
'G .�Q
Mailing Address (Conhacfor or Owner Performing Insfallati
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Authorized Sianature IConfracror or Owner Perfouqina Installationl
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Fire No. Count
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Phone No.
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Confractor License No. Master Lic. No. (Planf Elecf. Or
I
Phone No.
�o-ww � ra � i 6/YO STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY
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