P - 80399REQUEST FOR ELECTRICAL INSPECTION
�����. n O� � Minnesota State Board of Electricity `a
. � 1821 Universiry Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 -
(651) 642-OS00 www.electricity.state.mn.us "'
the work covered by this request. Enter remorks in ihis space and on the back of the white copy only.
P�b �,au-�. �� I--����� 8 S
Calculate Inspection Fee - This Inspection Request will not be accepted without fhe correct fee:
Ofher Installafions Fee # Service Enfrance Size Fee # Circuits / Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg. / TraFfic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTA �
Sign / Outline Ltg. Xfmr. �
Alarm/Remote Control
Swimming Pool
{ here certi ihat I ins the electrical installation described herein on the dates stafed:
Irrigation Boom Ro�9M� Dare.
Special Inspectio
Final Dafe G 2
Investigative Fee 2— �j �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
. OFFICE USE ONLY This requesf void 18 monfhs from validafion dafe prinfed in fhis box.
I��IN��l�ll�l�����l.l�lll���ll�l� � a° "�
* 0 8 8 6 2 0 6 2* lD6o
PLEASE PRINT OR TYPE
Requesf Date Rough-in inspection required? ❑ Yes No Inspection Other Than Rough-In: ❑ Ready Now Will Call
Z 2 � UO You musf call fhe inspecfor when ready Date Ready:
l
1, licensed conFractor ❑ company ❑ owner hereby request inspection o( the above electrical work at:
�ob Address (SMeet, Box, or Route No.) , � Giy r. �� Zip Code �_,
ownship Name or No. � Range No. � Fire
OccupaM _� � � „ � � � Phone No.
Power
Electrical Conhacror / Company Name
BLAINE HT0. A/C EL�:T �iC.
Mailing ----'1 ' y ---- r ing
�Co racf� pany or Ow�r P� erforming I�afion� y' J��� I�hone Numbgr���� I
�G/ I � t
� %v �J ^%�,
3 _ STATE BOqRD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY