P - 80736REQUEST FOR ELECTRICAL INSPECTION �
8�# U=19 8 Minnesota State Board of Electricity
, 1821 University Ave., Rm. S-128, St. Paul, MN 55104 �
Phone(612)642-0800
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. OFher:
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.
n-�cv � Uo � gve,rh-ead SU-Y i ce � n�e �us�i r,� ! oca_+�i or� .
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Calculate Inspection Fee - This Inspi
Other Fee
Mobile Home Park Stall
Sfreet Ltg./Traffic Sig.
Transformer/Generator
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimminq Pool..
m Request will not be accepted without the correc� fee:
# Service Entr ce Size Fee # Circuits/feeders Fee
� 0 to 200 A ((r(? �.00 0 to 100 Amps (,p.OD Z-(
Above 200 Am s Above 100 Amps
INSPECTOR'S USE ONLY TOTAL [��
fls �. • �C!
I herebvi certifv thaf I insoecled the electrical installallon described herein on the dates s�oted
� Investigative Fee - r" " � - � ��-" f"�`�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
.. OFFICE USE ONLY This requesf void 18 months (rom validafion date printed in fhis box.
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PLEASE PRINT OR TYPE
Request Date Ro h-in ins on r u�red?
ug pecli eq ' ❑ Yes Inspeclion 01her Than Rough-In: ❑ Reody Now Will Cal1
�� Z Z�� q (You must call the inspeclor when ready) Date Ready:
I, �licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Skeet, Box, or Route No City Zip Code
w�c�3 a�' st ��. �-;�cc �ai
Secfion No. Township Name or No. Ranqe No. Fire No. Counry
Occupant
ow►�.ers : I-4 �`5 j� — <
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Power Supplier �n •
Als � C3u��s �r_na
Elechical Conhocfor (Company Name)
BLAINE HTG. A,C ELECT., iNC.
Mailing Addr rtr e orming� nstalla
ANOKA, � 553�4
Aufhorized i ature �Co hacfor r ner PerForrtypg In:
Phone No.
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s!-(n �
rrb��e PDih+e �(r �oscui
Conhactor License No. f�aster Lic. Nc
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