P - 80802H
� REQUEST FOR ELECTRICAL INSPECTION
0-854-637 0 Minnesota State Board of Electricity -_
� 1821 Universiry Avenue Suite S-128, Saint Paul. Minnesota 55104-2993 _ _
(651) 642-0800 www.electricity.state.mn.us � � '
Home Duplex Apt. Bldg. Other: New Atldn
Commercial Industrial Farm Remod Repair
Air Conditioner Htg. Equip. Water Htr. Loatl 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.
NSP SAVER'S SWITCH IN5TALLATION
Ca/culate Inspection Fee - This Inspection Request will not be accepted without the correct fee.
Jther Installations Fee # Service Entrance Size Fee # Circuits / Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg. / Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign / Outline Ltg. Xfmr.
Alarm/Remot
Swimming P
I hereby certify that I inspected the electrical installation described herein an the dates stated:
Irrigation Boom Rough In Date
Investigative Fee F��� �. I�a�-2� '�I I
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
............................�.......,._......,W�.......�.u..........�,.... �- ...... ... .............................
OFPi�t� a��0yi_Y q� void 18 months from validation date pnnted in this box.
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, *08546376* `�7��
PL
Request Date Rough-In inspection required? � Yes ❑ Inspection Other Than Rough jn: � Ready Now d WNI Call
You must call the inspector when ready� Date Ready: 1�
I, [jQicensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Jo�� (Street, Box. or ut N,p;� City c�yr,y cv Zip Code:
9il•i �1� rR1�Ji.G i F�i '3'Z
Section No. Township Name or No. Range No. Fire No. County �
.�FF T
Electrical Contractor / Company Name
annsr� �c�c ca., tNC.
Mailing Address (Contractor, Company or Owner Performing Installatlon)
12Q$7 � AVE S. SAVA�GE. ��
Authorized Signature (Contrector, f�p-p�wner Perto
EB-00001A-12 5/1999 �� STATE BOARD COPY
Phone No. /61Z�2-17fi0
�
OFFtCE
Contractor License No. Master Lic. No. (Plent Elect. Only)
cno���
� (li12�41-4712 ! (812�90-3�5
Phone Number
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SEE INSTRUCTIONS ON BACK OF YELLOW COPY