P - 82083> E
REQUEST FOR ELECTRICAL INSPECTION
�-859-810 [�4 Minnesota State Board of Electricity _
�� 1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993 - _
(651) 642-0800 www.electriciry.state.mn.us �'�°
?C Home Duplex Apt. Bidg. Other: New Adtln
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 on/y.
N3P SAVER�s swrrcH
Calcu/ate Insnection Fee - This Inspection Reauesi will not be
Mobile Home Park Stall
Street �tg. / Traffic Sig.
Transformer/Generator
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
Swimmina Pool
0 to 200 Amps
Above 200 Amps
INSPECTOR'S USE ONLY
I hereby certify that I inspected the
Rough In
without the cor
�ircuits / Feeder
0 to 100 Amps
Above 100 Amps �
TOTAL���
fee.
on the dates stated:
Investigative Fee r��� � I V��2. %��'—� �
THIS INSTALLATION MAY BE ORDERED DI NNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
.Y, _.»......._�.....,.,_...,..,.,,.,.,,«_ , -.....»...-,---.w�.»�«�«�.- OFFICE USE ONIY This request void 18 months from validation date priMed in this box.
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*085981 Q4* �`i1.3
PLEASE PRINT OR TYPE
Request Date Rough-In inspection required? ❑ Yes 0 f� Inspection Other Than Rough-In: LiReady Now 0 Will Call
����� You must call the inspector when readyl Date Ready:
I, �] licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address (Street, Box, or Route No.) City Zp Code:
241 6TTH P�. NE FRIDI.EY 5�133
Section No. Township Name or No. Range No. Fire No. County
-"'-°-- °'- ----^°"---_ -�-".�..- lY1VRo
Occupant Phone No.
�t�RSOn� e�Er w ------
Power Supplier Address
NSP ,-� -----------
Electrical Contractor / Co y Contractor License No. Master Lic. No. (Plant Elect. Onty)
Mailing Address (Contractor, Company or Owner Performing Installation)
2300 TERRIT{iRtAL ROAD , SAINT P�►UL, MN 55"11d
Authorized Signature (Contrador, Company or Owner Performing Installation) Phone Number
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EB-00001A•12 5/1999 STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY