P - 80768REQUEST FOR ELECTRICAL INSPECTION
O—C754-596 []4 Minnesota State Board of Electriciry -_ _
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993
� (651) 642-0800 www.electricity.state.mn.us �'�--
Home Duplex Apt. Bidg. 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 of the white copy on/y.
NSP SAVER'S SWITCH lN5TAL1AT10N
Calcu/ate Insvection Fee - This Insnection Request will not be accepted without the correct 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.
Alarm/Remote Control
Swimming Pool
_ I hereby certify that I inspected the electrical installation described herein on the dates stated:
Irrigation Boom �* Rough In Date
X Special Inspection � � ,��
Investigative Fee Fina1 [�te` „����
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THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
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OFFICE USE ONLY This uest vad 18 months from validation date rinted in ihis box.
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085 596
PL
Request Date Rough-In inspection required? ❑ Yes ❑ I�Ip Inspection Other Than Roug7jn: ❑ Ready Now ❑ Will Call
You must call the inspector when readyf� Date Ready: ��
I, C3Qicensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Jo�Ocgirg�s (Street, B�o; �e Ng� Ciry ��Y Z�P ��3Z
uattau o � ri nt
Section No. Township Name or No. Range No. Fire No. Counry w�U�utw
/'•Y�/V�v\
��� R P Phone No. ���^����R�Q
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P�pplier Addre`s�s /�
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Electrical Contractor / Company Name Contractor License No. Master Lic. No. (Plant Elect. Only)
a�as�R �c�c co., tir+�c. cao7�at
Mailing Address (Contractor, Company or Owner Performing Installation)
12487 �00(VE AVE S. SAV . MN. 56378 (li12j841-4712 !(B1Z�3656
Authorized Signature (Contractor, Com ming Installation) Phone Number
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EB-00001A-12 5/1999 STATE BOARD COPY , ,� RSEE INSTRUCTIONS ON BACK OF YELLOW COPY