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REQUEST FOR ELECTRICAL INSPECTION �°
Minnesota State Board of Electricity �'
�
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 ���:
(651) 642-0800 www.electricity.state.mn.us `'�'
Apt.
Wafer Htr. Load Mgmt. Other:
Elec. Heaf Temp. Service
is requesi. Enter remarks in this space and on the
Repair
copy only.
WIRE GARAGE ,
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Installations Fee # Service Enhance Size Fee # Circuits / Feeders fee
Mobile Home Park Stall 0 to 200 Amps 2 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. 20 . 5�
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ected the electrical installation described herein on the dates stated:
Irrigation Boom Rough-in Dare
Special Inspection
Final �..�-� �� -�
Investigative Fee '
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validaiion date printed in fhis box.
I��uIII��II����I��NI���I��i�l(�I���� � a� -`�
* 0 8? 4 8 9 8 0* pZ� lJ
PLEASE PRINT OR TYPE
Requesf Dafe Rough-in inspection requiredZ ❑ Yes � No Inspection OFher Than Rough-In: ❑ Ready Now � Will Call
4- 3- 0 0 You musf call fhe inspecfor when ready Date Ready:
I, �'icensed contractor ❑ company ❑ owner hereby request inspection oE the above electrica) work at:
Job Address (Sfreef, Box, or Roufe No.) City � Zip Code .�
5634 4TH STREET N.E. FRIDLEY
Secfion No. Township Name or No. Range No. Fire No. County
Occupanf � � � Phone No.
Powar Supplier Address
Elechical Conhacfor / Company Name Confractor License No. Mosfer Lic. No. (Planf Elecf. Only)
WEST STAR ELECTRIC, INC. CA01936
Mailing Address (Contracror, Company or Owner Performing Insfallation)
6324 KELAND E N BROOKLYN PARK MN 55428
Authori ed nafure (Conhacfo , ny or Owne� Performing Installafion) Phone Number
( )537-0807
E& STATE BO Y SEE INSTRUCTIONS ON BACK OF YELLOW COPY