P - 80763REQUEST FOR ELECTRICAL INSPECTION
�' O-C754-6� 1 � Minnesota State Board of Electricity N- -
� 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 -__
(651) 642-0800 www.electricity.state.mn.us : ' �
Home Duplex Apt. Bltlg. Other: New Addn
Commercial Industrial Farm Remod Repair
Air Conditioner Htg. Equip. Water Htr. Load Mgmt. Other:
Dcyer 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.
N�P SAVER'S S"1lVtTCH It�TRLtA710N
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee.
�ther Installations Fee # Service Entrance Size Fee # Circuits / Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg. / Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL ��„
Sign / Outline Ltg. Xfmr. (�
Afarm/Remote Control
Swimming Po �
I hereby certify that I inspected the electrical installation described herein on the dates stated:
If�l9atl0� BOO�1 Rough In Date
� � Investigative Fee � � L �—! °�- ��,C� J J �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
. . . .............•--�-- --�•--•-- - ---•--•--...�.--•--�-�•-
OFFICE USE ONLY This request vad 18 months ham validation date printed in this box.
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*08546012*
Request Date Rough-In inspection required? ❑ Yes ❑ Inspection Other Than RougF�n: � Ready Now ❑ Will Call
�,�� You must call the inspector when ready� Date Ready: A � f+��
I, [�9icensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
J�Qi1� �Street, ��i�VC�I� ��ti FRl�:.EY zip �.�432
Section No. Township Name or No. Range No. Fire No. Counry �
C�' �' Phone No. �612j57Z-�
Power,Supplier Add s
IV:�t� `�g p���
Electrical Contrador / Com an Name Contractor License No. Master Lic. No. (Plant Elect. Onty)
�AAS''i'ER ELEC�C Ca., tNC. CAO1102
Mailing Address (Contractor, Company or Owner Performing Installallon) B�2 �-�7�� r ��Z w�
�zae7 goon� AvE s. sa�rnc�. �v. ��$ t� t�-�
Authorized Signature (Contractor, Com er PerfortningQ tM�¢tirly ^ h Phone Number
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EB-00001A-12 5/1999 STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY