P - 80811REQUEST FOR ELECTRICAL INSPECTION �
Q ��� �� g 3 � Minnesota State Board of Electricity
� 1821 University Ave., Rm. S-12S, St. Paul, MN 55104
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i Phone (612) 642-0800 `'�'
Home Duplex Apt. eldg. Other: New Addn
Commercial Industrial Farm Remod Re air
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 ihe back of the white copy only.
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Calculate Inspection Fee - This inspection Requesl wiil not be accepted withou� ihe 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 oN�r TOTAL �'/'�
Sign/Outline Ltg. Xfmr. . V�
Alarm/Remote Control
Swimming Pool
I hereb cerii that I ins ted ihe electrical installafion dexribed herein on the dales staled
Irrigation Boom Ra,gMln Dare
Speciallnsp "�
Investigative Fee Final Daro-� �` G�
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THIS INSTALLATION MAY BE ORDERED DlSCO TED IF NOT COMPLETED WITFfIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 months from validation dafe printed in this box.
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PLEASE PRINT OR TYPE
Request Da= � Rough-in inspection required? ❑ Yes No Inspection Ofher Than RougMn: ❑ Ready Now Will Call .
�You musf call the inspecfor when ready) Dafe Ready:
I, �{ licensed contractor ❑ owner hereby request inspecFion of the above electrical work at:
Job Address (SMeet, Box, or Roufe No.) � City � Zip Code
55�5 dr: � 55�-13Z
$ecfion No. Township Name or No. Range No. Fire No. County �� �
Occupanf Phone No.
� yl �J'1�'C2��
Power $upplier Address
Elechical Conkcrctor �Company Name) Conhacror ticense No. Master Lic. No. (Mani Elect. Only)
BLAINE HTG. A;C ELECT., WC
Maifing Address J fion) .
A �N 553G4
Authorized Si re (Con cfor or ner PerFormiryi InsfallaKon� Phone No.
� E �.� i -� �-(�ZOU
E&00001 A-11 /96 , SIATE�BOARD COPY - SEE INSTflUCTIONS ON BACK OF YELLOW COPY