P - 80788' REQUEST FOR ELECTRICAL INSPECTION
,. Q—U54-655 80 Minnesota State Board of Electricity _
1821 University Avenua Suite 5-128, 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. 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 back of the white copy only.
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Ca/cu/ate lnspection Fee - This Inspection Request will not be acceRted without
Mobile Home Park Stall
Street Ltg. ! Traffic Sig.
Transformer/Generator
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
0 to 200 Amps 0 to 100 Amps
Above 200 Amps Above 100 Amps
INSPECTOR'S USE ONLY TOTAL r
I hereby certity that I inspected the electrical installation described herein on the dates stated:
II'f198t1Of1 BOO Rough In Date
X Special lnspection 15.
Investigative Fee F�� �a� --�'? df
THIS INSTALLATION MAY BE ORDERED DI D IF NOT COMPLETED WITHIN 18 MONTHS.
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OFFICE USE ONLY This request vad 18 months from validatlon date printed in this box.
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*08546558* ����
a��EAr�19000i70 .
Request Date Rough-In inspection required? ❑ Yes ❑ Inspection Other Than Rough�n: O Ready Now ❑�II Call
(y�fq•}fp� You must call the inspector when ready� Date Ready: 1� ��.__ `_
I, �icensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
.Jo�c�� (street, ��$oul V� � C'h' FWDLEY Z�P ��'Zi
7 UU FA� A
Section No. Township Name or No. Range No. Fire No. County �
°4�1�'ER U I�iA L Pho�e rvo. (B12�74-9730
Pp�yQr, Supplier Addrgs�.�,
fV7t" P/�"LS �Fif.'E
Electrical Contractor / Com an Name Contractor License No. Master Lic. No. (PIaM E�ect. Onty)
MA.ST'ER ELE�C CO., iNC. CA019�,2
Mailing Address (Contractor, Company or Owner Performing Installation) /B�i��'—Q��iZ ���'�2�.7i.�J"J
12467 � AVE S. SAVAGE, (wNV. �
Authorized Signature y or Owner Performing Installa n Phone Number
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EB-OOOOtA-12 5/1 STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY