P - 82085�
, - �-859-$, 2 0
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%ctricity.state.mn.us
!C Home Duplex Apt. Bldg. Other: New Atldn
Commercial Industrial Farm Remod Repair
Air Contlitioner 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.
Calculate Inspecti<
�ther Installations
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
Transformer/Generator
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
Irrigation Boom
Speciallnspecti p.
NSP SAVER'S SWITCH
Fee - This Inspection Request wil/ not be accepted without the correci fee.
0 to 200 Amps
Above 200 Amps
INSPECTOR'S USE ONLY
that I insoected the elecVical
# Circuits / Feeders Fee
0 to 100 Amps
' Above 100 Amps
TOTA�
allation described herein on the dates stal
Date
Investigative Fe �� � ���''.-�-•-� I �a�-2o--c� % I
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
�..���.��wW» „w��»,���.���:�M��M OFFICE USE ONLY This request void 18 months trom validation date printed in this box.
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*08598120* °��/�
PLEASE PRINT OR TYPE
Request Date Rough-In inspection required? � Yes ❑!Qa Inspection Other Than Rough-In: eady Now � Will Call
���� You must call the inspector when ready! Date Ready:
I, �] licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address (SVeet, Box, or Route No.) City Zp C�:
5841 v�l ST NE FRID�EY 56�43'i
Section No. Township Name or No. Range No. Fire No. County
--------- ------ -°------------ -------"' �
OccupaM Phone No.
R�BE U� M ------
Power Supplier Address
NSP --------
Electrical Contractor / Company Name Contractor License No. Master Lic. No. (PIaM Elect. Only)
Mailing Address (Contractor, Company or Owner Performing Installation)
23�0 TERFtfTOR1AL ROAD , SAINT PAUL, MN 55114
Authorized Signature (Contractor, Company or Owner Performing4nstallation) Phone Number
�
EB-00001A-12 5/1999 STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY