P - 80796E
� REQUEST FOR ELECTRICAL INSPECTION
O'C7�4-643 04 Minnesota State Board of Electricity -
1821 University Avenue Suite 5-128, 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. 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 back of the white copy only.
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Calculate Inspection Fee - This Inspection Repuest will not be accepted without the correct fee.
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg. / Traffic Sig. Above 200 Amps Above 100 Am�
TransformedGenerator INSPECTOR'S USE ONLY TOTAL
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming P ,
I hereby certi that I ins ed the electrical installation described herein on Me c
Irrigation Bo Rouqh In Date
Investigative Fee F"� - I oate E�} ��� I
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THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
.�.L.y�LL.�.Y .yWw�•�•�Ww�W W4.� ��� �.� W • OFFlCE USE ONLY This request vad 18 marths from validation date printed in this box.
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Request Date Rough-In inspection required? ❑ Yes ❑ Inspection Other Than RougFiJn: ❑ Ready Now ❑ Will Call
M«„�r.,,,, You must call the inspector when ready� Date Ready: �� _______
I, [jQicensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Jo�� (Street, B��,gL,�ROU�e` � � City � �� Z�P �e�
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Section No. Township Name or No. Range No. Rre No. County �
Ocox�rw� ��E ��� Phone No.
4.J'4F7GY
Ppwp�,Supplier Add�s�,,,,, S ���
iv��• Mr•t.
Electrical Contractor / Com an Name Contractor License No. Master Lic. No. (Plant Elect. Onty)
a��sr�R �.EC�c co.. rNC. e�ao���
Mailing Address (Contractor, Company or Owner Pertorming Installation) ���2J�4�-Q7421 (81Zj8{i0-3�f5
1�887 BOONE AVE S, SAVAC�, M�V,
Authorized Signature (Contractor, Co or Perfortnin I' Phone Number
�__ � �
EB-00001A-12 5/1999 TATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY