P - 80792REQUEST FOR ELECTRICAL INSPECTION -
O'854-V47 � Minnesota State Board of Electricity _
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993
(651) 642-0800 www.e/ectricity.state.mn.us
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Repair
Air Conditioner Htg. Equip. Water Htr. X Load Mgmt. Other:
Dryer Range Elect. Heat Temp. Service
'X" above the work covered by this request. Enter remarks in this space and on the 6ack of the white copy only.
NSP SRVER'S SWITCH INSTALLATION
Ca/cu/ate Inspection Fee - This
Installations Fee #
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
Transformer/Generator
Sign / Outline Ltg. Xfmr.
Alarm/Remote Co 0
Swimming Pool
Irrigation Boom
Special inspection
Investigative Fee
THIS INSTALLATION
will not be accepted without the correct fee.
0 to 200 Amps
Above 200 Amps
INSPECTOR'S USE ONLY
I hereby
Rough In
BE
I IIIIII IIIII IIIII IIIII IIIII IIIII �II �II I�
*08546475*
�ircuits / Feeders Fee
0 to 100 Amps
Above 100 Amps
TOTAL t�
a .,
n described herein on the dates stal
IED DISZ`.�NNECTED IF NOT COMPLETED WITHIN 18 MONT
OFFlCE USE ONLY This request void 18 montlis from validation date printed in this box.
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I, []Qicensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
JolaOdtl� (Street, �KI.J 51 IYC C�� F�Q�•� zp C�'JL14ai
uar
Section No. Township Name or No. Range No. Fire No. Counly �
'9'1�CTCL1VY11YVwY �%) .riK� L Phone No. t$+�,c�.11 1�.7iV�i .
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P�PPlier Addrg�.�, S �) �
hR'L
���i���a�� ' t� co�ae�oeL�ic1ns� 10.�' Master Lic. No. (Plant Elect. Onty)
V
M�ilin �A� ress (�to�r,;Co�mp,Ca,n' or Owne�r P�erfortnin�g I:stal�78 �����gq1-0712 !(812�9(1-3555
Authorized Signa o Owner Performing Installatio �/� Phone Number
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EB-OOO�IA-12 5/1 STATE BOARD COPY SEE INSTRUCTIONS ON SACK OF YEL�OW COPY