P - 81540REGIUEST FOR ELECTRICAL INSPECTION -
7� 1� p� 0 Minnesota State Board of Electricity
0 1821 University Ave., Rm. S-128, St. Paul, MN 55104 �:
Phone(612)642-OS00
Home Duplex Apt. Bldg. Other: New Addn
Commercial Indusfrial 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 the back of the whi►e copy only.
P�ab G,a.u,5� 1���= ►� �= 7g�
Calculate Inspection Fee - This Inspection Request will not be accepied 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
Sfreet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL ��`�O
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimminq Pool
Special I
F� Date
Investigative Fee —�_____!_ Z_
TIi1S INSTALLATIa�Ll1AY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This requesf void 18 months from validafion date printed in this bo�
���������� �� � ` ���
II II III II Iil II III II ��� �� �I ��I I
�
* 0 7 5 1 8 2 0 2* �
PIEASE PRINT OR TYPE �7
Request � ^� Rough-in inspection required2 ❑ Yes No Inspection O�er Than Rough-In: ❑ Ready Now ill Call
'� 1� (You must call the inspecfor when ready) Dafe Ready:
I, ` licensed contractor ❑ owner hereby request inspection of ihe above electrical work at:
Job Addreu �Skeef, Box, or Roufe No.) City Zip Code
Section No. ownship Nome or No. � Range No. Fire No. � CounN ��
I Uccu� � w � ^ � � � / Phone No.
�1,1J rl � �� 1-� I �
IPower Supplier Address
Contractor (Company Name1�� Co qactor License No. Master Lic. No. �Plant Eleci. Only�
BLAINE FRQ. l�`C FI FCT.� INC. % 1 rLlt ��7/� /_
0
A-11
No.