P - 81184.
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REGlUEST FOR ELECTRICAL INSPECTION -
Minnesota State Board of Electricity '
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 -_ -
(651) 642-0800 www.electricity.state.mn.us
Home Duplex Apt.8ldg. Other: New Atldn
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 ana on tne nacK or rne wrnre copy orny.
P�SP SAVER'S SWtTCH INSTJ�.LA'f1CiM
Calculate Inspectic
�ther Installations
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
Transformer/Generator
Sion / Outline Ltg. Xfmr.
- This Insvection Reauest will not
0 to 200 Amps
Above 200 Amps
INSPECTOR'S USE ONLY
vted without the correct fee.
# Circuits / Feeders
0 to 100 Amps
Above 100 Amps
TOTAL �
�������� '� I hereb certify that I inspected the electrical installation described herein on the dates stated:
rigation Boom n in Date
peciallnspection � ��'
ivestigative Fee F� Dac� _��' �
L
THIS INSTALLATIOM MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
- _ ....................................................................__,.....�,.....-.....»_....,. .
OFFICE USE ONLY This request vdd 18 months from validation date printed in this box.
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'`08546061 *
PL�I�H�AKINI��l�OOOtIO
I R�� �� Rough-In inspection required? ❑ Yes ❑ Inspection Other Than RougFyki: ❑ Ready Now ❑ Will Call
You must cal! the inspector when ready� Date Ready; r�
I, [�Qicensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Jo��pg (Street, Bqx„�� �� City ���Y Zp Codg���3�
uou r u r � ri :�oA
Section No. Township Name or No. Range No. Fire No. County
•�:,�`L'i
(Bf�j671-d252
Pawan6upplier Addr@s�.,, � �,�
IY.7f� IY�l.
E ectrical Contraaor / an Name Contractor License No. Master Lic. No. (Plant Elect. Ony)
�'c�c co.. uvc. cn4���
Mailing Address (Contractor, Company or Owner Performing Installatian) o�� �—�i7�a � f��� J:�TJ
�zas� eoar� AvE s. s�v�. ann�. ��s t� t�-
Authorized Signature (Contractor, Company or Pertorming Inst I i � Phone Number
5�'�� c �
EB-00001A-12 5/1999 STATE BOAflD COPY SEE iNSTRUCTIONS ON BACK OF YELLOW CAPY