P - 82207� �Y-011-44(J 03
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REQUEST FOR ELECTRICAL INSPECTION �` E
Minnesota State Board of Electricity _- `s
1821 Universiry Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993 -__ _
(651) 642-0800 www.electricity.state.mn.us '.m�
X Home Duplex Apt. Bldg. 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 3AVER'S SWITCN
Calcu/ate Inspection Fee - This Inspection Request wil/ not 6e
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
TransformedGenerator
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
0 to 200 Amps
Above 200 Amps
INSPECTOR'S USE ONLY
�ted without the correct fee.
# Circuits / Feeders Fee
0 to 100 Amps
Above 100 Amps
TOTAL
���'"010. S�
I hereby certify that I inspected the electrical installation described herein on the dates stated:
Irrigation Boo Rough In Date
Special insp
Flna� oann.-. ^.z.o—o
Investigative Fee ..�
THIS INSTALLATION MAY BE ORDERED ECTED IF NOT COMPLETED WITHIN 18 MONTHS.
.......y;,�...........•••,�;; ...............................�,...•.��.�,:..:y..�.�,...�,.�.�r .. ....... .. .. . . . . . . .
I IIIIII IIIII IIIII III�I IIIII III IIII II� �I OFFlCE USE ONLY Thia request void 18 months from validation date printed in this box.
* 1 0 1 1 4 3* • �S ��
PLEASE PRINT OR TYPE
Request Date Rough-In inspection required? ❑ Yes ❑ N� Inspection Other Than Rough-In: ❑�eady Now ❑ Will Call
�27�� You must call the inspector when ready! Date Ready:
I, �j licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address (Street, Box, or Route No.) City Z�P �e�
613f 6TH ST NE FRID�EY 5543"t
Section No. Township Name or No. Range No. Fire No. County
- --- - "'- -----'-----'--- °--------- /'11�YM1
Oxupant Phone No. �
3AEF AMES T ------
Power Supplier _ �'� n Address
NSP � � ' ----------
Electrical Contractor / Company Name Contredor License No. Master Lic. No. (Plant Elect. Only)
G CORPQRATION GA 00883
Mailing Address (Contractor, Company or Owner Performing Installation)
23aD TERRITORIAL ROAD , SAINT PAU�, MM 55114
Autharized Signature (Contractor, Company or Owner Performing Installation) Phone Number
�
EB-00001A-12 5/1999 STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY