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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 '��;'
Other: New Addn
Commercial Industrial Farm iTemod Re ai
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 only.
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Calculate Inspection Fee - This Inspeciion Request will not be accepted without the correcf 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 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY T � �
Sign/Outline Ltg. Xfmr. �`
Alarm/Remote Control
Swimming Pool
I hereb certi fhat I ins ected the electrical installafion described herein on the dates stated
Irrigation Boom Rough-In Date
Special Inspection
Final Dal�-�
Investigafive Fee �) � ^ Q�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
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OFFICE USE ONLY This requesf void 1 8 monlhs from validation date prinfed in this box.
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* 0 8 2 6 2 0 U 8* � 2$�1�.
PLEA PRI T OR TYPE
Request Dafe Rou h-in ins ection re uired?
g p q ❑ Yes No Inspection Other Than Rough-In: Ready Now ❑ Will Call
� �� (You must call the inspector when ready) Da}e Ready:
I, �icensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address �Street, Box, or Route No.) Ciy Zip Code
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Secfion No. Township Name or No. Ranpe No. Fire No. Counfv�
Occupant
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Power $upplier
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Elecirical Conhactor �Company Name)
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Mailing Address (Con ractor or Owner
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Authorized Sianafure �Contractor or O�
Address
Insfallation)
Phone No.
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License No. Master Lic.
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY