P - 82220' REQUEST FOR ELECTRICAL INSPECTION
U � � � % - � � O � Minnesota State Board of Electricity ;;
� Q 1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993
t (651) 642-0800 www.electricity.state.mn.us .
, Home Duplex Apt. Bldg. Other: New Addn
Commercial Indusirial Farm Remod Repair
Air Conditioner Htg. Equip. Water Hir. 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.
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�io C��ct;�,�.� `1�1�i= 7�$5
Calculate Inspection Fee - This Inspection Request will not e accepted wi►hout the correct fee:
Other Installations Fee # Service Entranc e Fee # Circuits / Feeders Fee
Mobile Home Park Stali � 0 to 00 A s Q�. �,(317 0 to 100 Amps
$treet 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 ins cted the eleckical installafion described herein on the dates sfafed:
Irrigation Boom Rough-In D r.
Special lnsp _� y �U o
Final Dak
Investigative '. ;� -� ��--��I
THIS INSTALLATION MAY BE ORDERED DI ED IF NOT COMPLETED WITFIIN 18 OM NTHS.
OFFICE USE ONLY This requesf void 18 months from validafion dafe printed in this box.
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PLEASE PRINT OR TYPE
Request Date ] � Rough-in inspection required? ❑ Yes No Inspecfion Ofher Than RougMln: ❑ Ready Now ill Call
��� �v� You must call the inspecror when ready Date Ready:
I, icensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address �Sfreef, Box, or Royfe No.) ��� . City�� �� Zip Code
" S� ZI
Secfion No. TownshigName or No. Range No. Fire No. Cou
�, 8 �
Occ' nf � �� � Phone No. _ �
Power Supplier � � Addres� �/
a�1/ 1-2 , S�j l 1'� (�24 �
"j •• [.1�'a U 3 i I �'
Electrical Contracror / Company Name � Conhacror License No. Master Lic. No. (Plant Elect. Only)
BLAINE HT(�. A/C ELECT.. INC. ���
Mailing Ad h r ee g Insfallation�
ANOKA MN 55304
Aufhorized i afure (C frac r, C mpany or Ow.er Performing I s Ilafion) � Phone Number
� �� �
EB-OOOOtA- 5/1999 STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY