P - 80771v
� REQUEST FOR ELECTRICAL INSPECTION F
O'C�54-593 1� Minnesota State Board of Electricity H-
� 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993
(651) 642-0800 www.electriciry.state.mn.us
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Repair
Air Contlitioner 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 hack of the white copy only.
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Calculate Inspectii
Other Installations
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
TransformedGenerator
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
Fee - This Inspection Reauest will not be acceoted without the
#
0 to 200 Amps 0 to 100 Amps
Above 200 Amps Above 100 AmG
INSPECTOR'S USE ONLY TOTAL
Rough In
tnat i
the electrical installation described herein on the dates stated:
I I �nvestigative Fee I I� l ��'' ��= 3 E----�'.�/ �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.--
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OFFICE USE ONLY This request vad 18 months from validation date printed in this box. �
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*08545931 * �"�`3
I, [aQicensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Jo�d��s (Street, Qp�,p�9oyt@�p.)� Ciry ��-y CY Zip Cod���
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Section No. Township Name or No. Range No. Fire No. Counry �(d
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PoYwn6upplier
�Ya�"
e tn I ontractor / Com Name
:R �.EC'�C Ct�., itVC.
Mailing Address (Contractor, Company or Owner PeHor
12467 BQONE AVE S, SA�
�
Authorizetl Signature (Contracta, C wne
Phone No. �a���q,�—.�w}
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Contractor License No. Master Lic. No. (Plant Elect. Only)
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Installation)
I.5�378 �612�41-4712I (012�-3�55
aiag_lnstallation) Phone Number
EB-00001A-12 5H999 1'�/ �TE BOARD COPY ���/ EJ SEE INSTRUCTIONS ON BACK OF YELLOW COPY