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Home Duplex
Commercial Industrial
Air Cond. Hta. Eaui
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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 "�'
Apt. Bldg. Other: New Addn
Farm Remod Re air
Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
request. Enter remarks in fhis space and on the back of the white copy only.
Calculate Inspeciion Fee - This Inspection Requesi will not 6e accepted wiihout ►he correct fee:
Other Fee # Servic trance Size Fee # Circuits/Feeders
Mobile Home Park Stall t 20 mps 0 to 100 Amps
Street Ltg./Traffic Si�. Above 200 Am s Above 100 Ai
Transformer/Generator INSPECTOR'S USE ONLY T�i
Fee
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control �
Swimming Pool � —� ���
I hereb certi �at I ins fed the electrical installafion described herein n fhe af s
Irrigation Boom RougMn Dafe
Speciol Inspecti �� �O — �
Final � D
Investigative Fee C� — — l�
THI3 INSTALLATION MAY BE ORDERED DISCONNE TED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This request void 18 months from validafior date prinTed in this box.
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PLEASE PRINT OR TYPE
�R uest Rough-in inspection required? ❑ Yes ❑ No Inspection O�er Than RougMn: ❑ Ready Now Q Will Call
1 ' ''�'t � �`(ou must call ihe inspecror when ready) Date Ready:
I, ❑ licensed contractor ❑ owner hereby request inspection of the above electrical work at:
lob Address (Sheet, Box, or Route No.) Ciry ` Zip Code
S"LC) UJ ` ryt e r� �''� � p � � Z-
Sechon No. Township Nome or No. � Range No. Pire No. County �
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Occ panf Pho`c\, iJ �/ ' �� ��
Power Su,p�liej Address "
/�/c°� J� c� �%� 0 L l�e,� �,
ElecFric onhacfor (Company Name) �� �� r Conhacfor License No. Masfer Lic. No. (Plant Eleci. Only�
�YL-i4�. ' �� �.� C �OD �
ilin Address (Conhacfor or Owner Pe rming Installafion)
i ��� � Z�
Authoriz ignature onhacfor or Owner e rming Insfallation) Phon No.
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1 A-11 8f96 STATE BOARD CO - SEE INSTRUCTIONS ON BACK OF YELLOW COPY �