P - 81262� REQUEST FOR ELECTRICAL INSPECTION ��,
7�1- 8 51 � Minnesota State Board of Electricity
iJ 1821 University Ave., Rm. 5-128, St. Paul, MN 55104
Phone (612) 642-0800
"R" above Poe work covered by this reQUesf. tnier remarks in fhis spoce pnd on fhe back ot Ihe whife ropy only.
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Calcubfe Inspecfion fee - 7his lnspec�ion Requesf will no( be occep�ed wifhout fhe mrrecf fee:
Other Fee #, Service Entrance Size Fee # Circui[s/Feeders Fee
Mobile Home Park Stall
Street Ltq./Traffic Siq.
INSPECTOR'S USE ONLY
Boom
0 to 100 Amps
Above 100_
ook
.�
Invesfigative Fee ^P � ��.:. • % � ..._. [ ��/ C � �—L� y`T
fH15 INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WI IN 18 MO HS.
OFFICE USE ONLY ihis requs�t void I B momhs from validotion dale prinkd in this box.
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PLEASE PRINT OR TYPE
qaezt Roughin inspecfion requlred? ❑ Yes Inspection O�her Than R«ghAn: ❑ keady Now III Coll
�ZO —�' q (You mus� wll the inspxiw when reody� Dme Ready:
licensed canhactor 0 owner hereby request inspection o! the obove elecirical work at.
� Address ISneer, Box, or RyWa No.� '_ , CiN_ .. Zio Code .
]onimcror�Compony Name)
BLAINE HT�Q. A:C ELECt. INC.
Yerlorryy�g InsNllalion� y, Phone No.
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STATE BOApp COPY - SEE INSiiiUCTONS ON BACK OF YELLOW COPY