P - 83624REQUEST FOR ELECTRICAL INSPECTION �.
�Q: �%� Q�� m Minnesota State Board of Electricity
.e °� �a 1821 University Ave., Rm. S-128, St. Paul, MN 55104 �,
Phone(612)642-0800
ome Duplex Apt. Bldq. Other. New Addn '
Commercial Industrial Farm Re od Re air
Air C�R I. g. 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 Inspection Request will not be accepted without the correct 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 TOTAL
Sign/Outline Ltg. Xfmr.
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Alarm/Remote Control ���'� ` � � �
Swimming Pool
I hereb certi that I ins ecied fhe elxhical installafion described herein on fhe dates sfated
Irrigation Boom aooyh-f� Dore
Special Inspecti
Investigative Fe ���I ,e �ly�%�r�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This requesf void 18 monfhs from validafion dafe prinfed in this box.
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* � 4 9 4 9 � 3 8* PLEASE PRINT OR TYPE
Requesf Dafe Rough-in inspecfion required? ❑ Yes
/� �. QWv�' Inspecfion Other Than RougMn: ❑ Ready Now�FCall
(You must call the inspector when ready) Date Ready:
I, �'ficensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sheet, Box, or Roufe No.) City Zip Code
F � ' � �� �
Section No. Township Name or No. Range No. Fire No. County
Occupanf Phone No.
`�`�t � 55�-����7
Power Supplier
BLAINE HTG. G EI.It '
Elechical Conhacid�g�p��RAL AVE. �!. �=.
ANOKA. MN �S.^-nn.
Mailing Address ��onhactor or O�ier Performing Installatio
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EBOOOOIA-11 i8/96 STATE BOARD COPY
Conhactor License No.
�' C� ( � �
Masfer Lic. No. (Plant Elect. Only)
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