P - 82086f �-859-813 80
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 -_ _
(651) 642-0800 www.e/ectricity.state.mn.us
X Home Duplex Apt. Bidg. Other: New Atldn
Commercial Intlustrial 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.
Calcu/ate Inspecti�
�ther Installations
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
TransformeNGenerator
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
Irrigation Boorri'3 ►�� r ti
NSP 3AVER'S 3WITCH
Fee - This Inspection Request will not be
0 to 200 Amps
Above 200 Amps
INSPECTOR'S USE ONLY
I hereby certity that I
Rough In
without the correct fee.
Circuits / Feeders
0 to 100 Amps
Above 100 Amps
TOTA�
installation described herein on the dates sfated:
Finel � Date
Investigative Fee /'L--�2
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WI HIN 18 MONTHS.
��� OFFICE USE ONLY This request void 18 manths from validation date priMed in this box.
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PLEASE PRINT OR TYPE
Request Date Rough-In inspection required? � Yes ❑ Nd Inspection Other Than Rough-In: eady Now ❑ Will Call
���� You must call the inspectar when ready! Oate Ready:
I, �] licensed contractor ❑ company ❑ owner hereby request inspection of the above e{ectrical work at:
Job Address (SVeet, Box, or Route No.) City �P C��
440 5TTH P� NE FRIDLEY 55432
Section No. Township Name or No. Range No. Fire No. County
-°--°°° ----- °-----'----- -°°----"- �
Occupant Phone No.
HAG N ANNETTE M ------
Power Supplier Address
NsP ----------
Electrical Contractor / Company Name Contractor License No. Master Lic. No. (Plant Elec[. Only)
Mailing Address (Contractor, Company or Owner Perfarming Installation)
2304 TERRITORIAL ROAD , SAINT PAUL, MN 55114
Authorized Signature (Contractor, Company or Owner Pertorming Installation) Phone Number
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EB-00001A-12 5/1999 STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY