P - 81619��
REQUEST FOR ELECTRICAL INSPECTION E
�f 0��-�� � � Minnesota State Board of Electricity F.- e
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 -_ ,
(651) 642-0800 www.electricity.state.mn.us :
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Repair
Air Conditioner Htg. Equip. Water Htr. :�; Loatl 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 on/y.
I�i�i=� �.tt.�1�:F��:�; �1�'i ��i�l°i 1#�`c:iir'�f..1.A7'iC�tv
Ca/cu/ate Inspection Fee - This Inspection Request will not be accepted without the correct fee.
Mobile Home Park Stall
Street Ltg./ Traffic Sig.
Transformer/Generator
Sign / Outline Ltg. Xfmr.
Alarm/Remote �ontrol
0 to 200 Amps 0 to 100 Amps
Above 200 Amps Above 100 Amps
INSPECTOR'S USE ONLY TOTAL
I hereby certity that I ins ected the electrical installation described herein on the dates stated:
Irrigation Boom R
ough In Date
Special inspection �p,�1p
Investigative Fee � Date���z� /
1
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
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� �pi PLEASE PRINT OR TYPE
Request Date Rau h-In inspection re uired? ❑ Yes ❑ Inspection Other Than Rough�lA: ❑ Ready Now � Will Call
fi�i�,�[.?t��.� Y u must call the in pector when ready! Date Ready: Q�11�����
I, �fcensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
City Zip Code:
Job Address (Street, Bax, or Route No.) ��{ ���Y ���,�
l7(.%'(l�� F.:t3Ra �l'd� i�3E
Section No. Township Name or No. Range No. Fire No. County
Oxu ant Phone No.
�=1�H S5 � !1HRlSTC�PHE�Z LLC?Yf?
Power Supplier Address
N�P MF'L� G�Fi CE
Co t actor License No
�sa�
r�a�ti��i-as�o
Electrical Contractor 1 Company Name n r . Master Lic. No. (Plant
n�.��-r�� ��..�c:�� c c: �7. , � r�c_:. cao � � �z
Mailing Address (Contractor, Company or Owner Performing Installatlon)
�� NE �VE S. SAVAGE tviiV ��378 (7�3jzi93�-d�3St(952)$8CI-�.�i5a
Phone Number
orize ure (Contractor, Company or Owner Performing Installatlon) � �
=B-0 00 A-12 1999 STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY