P - 82111REQUEST FOR ELECTRICAL INSPECTION �" E
1-011-621 � Minnesota State Board of Electricity ti:- `�
' 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 _ -
(651) 642-0800 www.electricity.state.mn.us : `
x Home Duplex Apt. Bldg. Other: New Addn
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.
Calculate Inspecti�
�ther Installations
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
Transformer/Generator
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
N3P SAVER'S SWITCH
Fee - This Inspection Request will not be
:e # Service Entrance Size Fee
0 to 200 Amps
Above 200 Amps
INSPECTOR'S USE ONLY
without the correct fee.
Circuits / Feeders Fee
0 to 100 Amps
Above 100 Amps
TOTAL
20.60
I hereby certi that I inspected the electrical installation described herein on the dates stated:
irrigation Rough In Date
Speciall +
F'inel � Date _ �
Investigative Fee p2� %
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
u �wLL�.� �• �•��� L.L yLL� 4 L W u y�•OFFIi;E USE ONLY This request wid 18 months trom validation date printed in this box.
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PLEASE PRINT OR TYPE
Request Date Rough-In inspection required? ❑ Yes 0 ND Inspection Other Than Rough-In: LMPleady Now ❑�II Call
��Z&� 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 (Street, Box, or Route No.) City Z�P �e�
21 � 1/2 WAY NE FRfDZEY MN 55432424 56432
Section No. Township Name or No. Range No. Fire No. County
---------- ------ --------------- ------------ ANGKA
Occupant � Phone No.
B4EDIGHEIMER ELWIN L ------
Power Supplier Address
NSP �� �' �,�
7 ------------
Electrical Contractor / Company Name Contractor License No. Master Lic. No. (Plant Elect. Only)
H E G'TRIC �R ATI N GA
Maiiing Address (Contractor, Company or Owner Performing Installation)
2300TERRITURIAI. RC?AD , SAIMT RAUL, MN 551't4
Authorized Signature (Contractor, Company or Owner Performing Installation) Phone Number
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EB-00001A-12 5/1999 STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY