P - 84185REQUEST FOR ELECTRICAL INSPECTION
5���� 3 0 2 Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
� Phone(612)642-0800
Home Duplex Apt. Bldg. Other: New Addn
Commercial Indushial 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 ihis request. Enter remarks in this space and on ►he back of ihe white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted withouf 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 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL �
Sign/Outline Ltg. Xfmr. �/G/- /-/� �� ' �``��
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ted the elechica� installation described herein on the dates stated
Irrigation Boom Rouah-In Dare
I Investigative Fe� V� 0_( -�� < �� I VU1eZ— �- ��
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 monihs from validation date printed in this box.
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* � 5 5 3 3 ��L 1�K PLEASE PRINT OR TYPE
RequesT Date Rou h-in ins ion r uired?
I��� y�� g pecf eq ❑ Yes No Inspecfion Ofher Than Rough-In: ❑ Ready Now ill Call
(You must call the inspector when ready) Date Ready:
I, � licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sheet, Box, or Route No.) � 3 Ciy Zip Code
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Section No. Towns ip Name or No. �- Range No. j Fire No. County
v� �'�-@ 1!�
:onhactor (Company Name�
BLAINE HTG. AIC F1ECT., INC.
55304
Authorized
EB-0000
Phone
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Phone No.