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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
New I IAddn
" Commercial Industrial Farm Remod Re a
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above ihe work covered by this request. Enter remarks in this space and on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted withoui the correct fee:
Other Fee # Service Entrance Siz Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps -- 2,�"— t 0 to 100 Amps ,S .
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL ��
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
I hereb certi that I inspected fhe electrical installation described herein on the dates stated
Irrigation Boom Rough-In Dare
Special Inspectio
Final ` � �
Investigative Fee �
THIS INSTALLATION MAY BE ORDEREp DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 monfhs from validafion dafe prinfed in this box.
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* 0 4 7 1 4 3 6 6�k PLEASE PRINT OR TYPE
Req est Date Rou h-in ins ection re uired? pec g ❑ Ready Now �Will Call
g p q ❑ Yes �No Ins tion Ofher Than Rou h-In:
�'�� � (You musi call fhe inspec}or when ready) Date Ready:
I, �icensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address �Sfreet, Box, or Route No.� City Zip Code
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Section No. Township Name or No. Range No. Fire No. Counfy
Occupanf Phone No.
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Power Supplier Address
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Electrical Contractor (Company Name) Contracfor License No.
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Address (Conkactor or Owner Performing Instollofion)
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ed Signature (Conhactopor Owner Performino Installationl
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A-11 8/96 •' ,
STATE BOARD COPY
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iTRUCTIONS ON B.
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Master Lic No. �Plant Elect. C
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Phone No.
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_LOW COPY