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REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electriciry �;-
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993
(651) 642-0800 www.electriciry.state.mn.us : `
Home Duplex Apt. Bldg. Other: New Addn
Commercial Intlustrial 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 on/y.
NSP SAVER'S SWITCH INSTALLA710N
Ca/cu/ate Inspection Fee - This Inspection Repuest wil/ not be accepted without the correct fee.
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
TransformedGenerator
Sign / Outline Ltg. Xfmr.
Alarm/Remote �I�]
0 to 200 Amps 0 to 100 Ai
Above 200 Amps Above 100
INSPECTOR'S USE ONLY
TOTAL
� I hereby certi(y that I inspected the electrical installation described herein on the dates stated:
IIT198t1011 BOOfII Rough In Date
X Special Inspection 15.�
Investigative Fee F� � — 2-° -� �
THIS INSTALLATION MAY BE ORDERED DIS ONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
��u � y� OFFICE USE ONLY This request void 18 montl�s from validation date printed in this box.
Illllllllllllllllllllllllllllll�illlhlllll� � aa- �
*08546392* �7��
Request Date I Rough-In inspection required7 ❑ Yes ❑� I Inspection Other Than Rougll-�n: ❑ Ready Now 0�II Call
nare�rin You must call the inspector when rea Date Ready: ��
I, [jQicensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Jo�B�l�g� (Street, B,q�,�o{ F�e� City F��� zP cod�32
uao;i � i M 5 i
Sec[ion No. Township Name or No. Range No. Fire No. County �
�E � E Phone No. �812�71-714£
Pow6r.SuPPlier AddrgsS,,, S �F� r�
IYLN� Pf��4
�n�a or/�olrlp�ny� �rt ' is� Contracto��11� Master Lic. No. (Plant Elect. Only)
C:'TRi v �•��.
Mailing Address (Contractor, Company or Owner Perfortning Installation)
12a87 BOO(� AVE S. SAV , MN. 5�378 (�12j941-07'!21 (B12jS�-3555
Authorized Signature (Contractor r Owner Performin���L � �hone Number
� �
EB-00001A-12 5/1999 STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY