P - 81183E
' REQUEST FOR ELECTRICAL INSPECTION
� O—C754-629 30 Minnesota State Board of Electricity -
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993
(651) 642-0800 www.eleciricity.state.mn.us
Home Dupiex 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" a6ove the work covered by this request Enter remarks in this space and on the back of the white copy on/y.
NSP SAVER'S S�MTCH INSTAL.tA'iiON
Ca/cWate Insnection Fee - This Insoection Reauest will not be accevted without the correct fee.
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
Transformer/Generator
Sign / Outline Ltg. XTmr.
Alarm/Remote Control
0 to 200 Amps
Above 200 Amps
INSPECTOR'S USE ONLY
0 to 100 Amps
Above 100 Amps
TOTAL �
ao�s
n described herein on the dates stated:
Investigative Fee F� � I�at�. L S=� / I
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
.......--° --•-• ................................................_..-
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OFFICE USE ONLY This request vdd 18 months from validation date printed in this box.
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Request Date Rough-In inspection required? � Yes ❑ Inspection Other Than Rouah�n: 0 Ready Now ��II Call
��q.��� You must call the inspector when ready� Date Ready: �� M��A�
I, []Gicensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Jqae�ldr�ss(Street,�acl3outeJya)� Ciry �aEY Z�P�e�a�,�,�
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Section No. Township Name or No. Ranue No. Fire No. TCountv ANIi1Kd
LISA A
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Mailing Address (Contractor, Company or Owner Performing Installation)
12487 BOONE AVE S, SAVAt�, l�i, 55378
Authorized Signature (Contractor, C wner Perfor �taNati
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EB•00001A-12 5/1
STATE BOAqD COPY
Phone No. `Q���� M87
tv p�,r�-�rr
�Q42�44-0712 / (61��-35�5
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SEE INSTRUCTIONS ON BACK OF YELLOW COPY