P - 80785� REQUEST FOR ELECTRICAL INSPECTION " E'
Q—C�54-654 � Minnesota State Board of Electricity
� 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 -_ _
(651) 642-0800 www.e/ectricity.state.mn.us : '
Home Duplex 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" above the work covered by this request. Enter remarks in this space and on the back of the white copy on/y.
I�P SAVER'S SWITGH IIV5TALLAT►ON
Calcu/ate lnspection Fee - This Inspection Request will not be accepted without
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
Transformer/Generator
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
0 to 200 Amps 0 to 100 Ai
Above 200 Amps Above 100
INSPECTOR'S USE ONLY
In
TOTAL
Date
Investigative Fee FN'ei �— -" I oate,l/����
/
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS
���Y��v.� YwW�.Y���wY.4.� .�W���•�.OFFlCE USE ONLY�Triis request void 18 monihs from validation date printed in this box�„
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*Q8546541 * ���9
PLfi+�A�IN��O
Request Date Rough-In inspection required? ❑ Yes � yp Inspection Other Than RoughrM: ❑ Ready Now ❑ Will Call
Q����g You must call the inspector when readyl' Date Ready: �� �s�,��
I, []IGicensed contractor ❑ company ❑ owner hereby request inspection of the above e{ectrical work at:
�oj���g (Street, B��rl�i�►� (� c�'� FRlC?LEY zip c��474
s»���
Section No. Township Name or No. Range No. Fire No. County ��b
ROBERT K
Addrgsy�„�� S ��+�
NI��L
MAa'TER ELEGG'TTRtC CO.. IfVC. I
Mailing Address (Contractor, Company or Owner PeAortning Installatio
12A67 HOOWE AVE S. BAVAG�. AdM. 653,��
Authorized Signature (Contractor, Com�p�cc�wner Performing Installation)
EB-00001A-12 5/7999�� STATE BOARD COPY
Master Lic.
(812j941-0712 ! (Q12�90-35�5
Phone Number
\ �
SEE INSTRUCTIONS ON BACK OF YELLOW COPY