P - 80767REQUEST FOR ELECTRICAL INSPECTION
Q-854'S.77 � Minnesota State Board of Electricity __
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993
, (651) 642-0800 www.electricity.stafe.mn.us : -'
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial 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 or tne wn�te copy onry.
NSP SAVER'S SIAflTCH INSTALtAT1UN
Ca/culate Inspection Fee - This Inspection Request will not be accepted without the correct fee.
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
TransformeNGenerator
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
0 to 200 Amps
Above 200 Amps
INSPECTOR'S USE ONLY
I hereby certity that I inspected the
Rough In
# Circuits / Feeders I
0 to 100 Amps
Above 100 Amps
TOTAL ,q
��ii
allatlon described herein on the dates
Investigative Fee '— Finai /� �` I ��� �?-,,(�f/ I
C °
THIS INSTALLATION MAY BE ORDERED DISCO CTED IF NOT COMPLETED WITHIN 18 MONTHS.
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OFFICE USE WM.Y This request vad 18 montlis from validation date printed in this box.
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Request Date Rough-In inspection required? ❑ Yes ❑ Inspection Other Than Roughln: ❑ Ready Now ❑ Will 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:
Joj�$Q�g� (Street, B�o1Rgu�e Ng� � City ��Y Zip Code:
u�u�9 t� v�rp► �543Z
Section No. Township Name or No. Range No. Fire No. County �*A
�Y PAUI. A Pno�e No. ($12j:'1T1-8QB0
Pqyy�$ypplier Addrgs�, S ��CE
IV�72� M"l.
Electrical Contractor / Company Name Contractor License No. Master Lic. No. (Plant Elect. Only)
�AAST'ER Ei.EC'ii�tC CO.. iNC. CAQI1AZ
Mailing Address (Contractor, Company or Owner Perfortning Installation)
12467 BOOWE AVE S. SAVAS�. MN. �'i378 (O'l2j949-rl712! (Q'l2�0-35�'i
Authorized Signature (Contractor, Comp or Owner Performing Install ) Phone Number
�73 ( >
EB-00001A-12 5/1999 STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY