P - 80779` REQUEST FOR ELECTRICAL INSPECTION
'f ' Q—��4-585 �7 Minnesota State Board of Electricity F—
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 Addn
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 oi the white copy onry.
I�..SP SAVER'S 91MTCH lNSTALLATION
Calcu/ate Inspecti<
�ther Installations
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
Transformer/Generator
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
Fee - This Inspection Request will not be accepted without the correct fee.
0 to 200 Amps 0 to 100 Amps
Above 200 Amps Above 100 AmE
INSPECTOR'S USE ONLY TOTAL
I hereb certify tt�at I inspected the electrical installation described herein on the c
Fnuah In Date
F�� � - o �`�-�s--�v I
Investigative Fee ____��
THlS INSTALLATION MAY BE ORDERED D SCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This request void 18 moMha trom valitlation date printed in this box.
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*08545857
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Request Date Rough-In inspeciion required? � Yes 0 No Inspection Other TF�an Rough-In: Aeady Now Will Call
You must call the inspector when ready� Date Ready: x
I, �icensed contractor ❑ company ❑ owner hereby request inspection of the above electrical �ia�
Job Address (Street, Box, or Roufe No.) City Zip Code:
00310 �p WAY NE ��-� 32
Section No. Township Name or No. Range No. Fire No. CouMy
�
Occupant Phone No.
POTA9EK ORE�URY D
Power Supplier Address
� �1�.�'J ��' .riE
Electrical Contractor / Company Name Contractor License No.
MA9TER ELEG"Ti�C GO.� 1[VC. CA011A2
Mailing Address (Contractor, Company or Owner Performing Installation)
Signature
EB-00001A-72 5/1999 �� l STATE BOARD COPY
S74-i1�3
No. (Plant Elect. Ony)
' 041-4712 ! �12 8�0-35$$
Phone Number
� 1
SEE 1NSTRUCTIONS ON BACK OF YELLOW COPY