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Home Duplex
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Eoard of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
New
Commercial Industrial farm Remoc
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy
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Calculate Inspection Fee - This Inspec►ion Request will not be accepted without the correc► fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Ar
Transformer/Generator INSPECTOR°S USE ONLY TOT,
Sign/Outline Ltg. Xfmr. �
Alarm/Remote Conhol
Swimming Pool
� I hereb certi fhaf I ins ected the elechical installation described herein on the
Irrigation Boom Ro�gh-I� Date
Special Insoe ' /
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Fee
5 d
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 monfhs from validafion dafe prinTed in fhis box.
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I IIII I) I�) II III I) II� (I I��I �II I) II) II III I IIII �
* � 5 1 0 9 4� 5# PLEASE PRINT OR TYP �
RequesfQ/a te Rough-in inspection required? Yes ❑ No Inspeciion Ofher Than Rough-In: ❑ Ready Now Will Call
8�l]�/g' (You must call the inspector when ready) Date Ready:
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I, �licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sheet, Box, or Roufe No.) Cify Zip Code
7 'i O M .' V. � �i�. `a�/e
Section No. Township Name or No. Range No. Fire No. County
Occupanf
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Power Supplier Addr�
Elechical Conhoctor (Company Name)
C• �� �,,�.`,��, �PP�•�'.'� � E�� �
Maili g Address (f% nhactor or Owner Performing Installation)
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Authorized Signafur onhacfo r Ow Performing Installafion)
B-00001 A-11 8/9 STATE PY - SE
Phone No.
Conhactor License No.
L�%'O L ! fv
�.��o�Ks►
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TRUC770NS ON BACK OF YELLOM
Master Lic. Na �Plant Elect. Oi
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No.