P - 81204" REQUEST FOR ELECTRiCAL INSPECTION �"s°'
�' � Q-854-607 [�9 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. 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.
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Calculate Inspecti�
Jther Installations
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
Transformer/Generator
Sian / Outline Lta. Xfmr.
Irrigation Boom
Special Inspecl
Fee - This Insvection Reauest will not be
0 to 200 Amps
Above 200 Amps
INSPECTOR'S USE ONLY
I herebvi certN that I
�stigative Fee � �
THIS INSTALLATION MAY BE ORDERED
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*Q8546079*
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without the correct fee.
Circuits / Feeders
0 to 100 Amps
Above 100 Amps
TOTAL
Date
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IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 monMs from validation date printed in this box.
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equest Date Rough-In inspection required? � Yes ❑ Inspection Other Than RoughJn: ❑ Ready Now ❑ Will Call
�,�� You must call the inspector when rea� I Date Ready: �� � f.'� I
ov�—
I, [�censed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Joy,� (Street, q�,py,� r�QL � ah' FRfD1,EY Z�P �°`'r,�gq'� j'
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Section No. Township Name or No. Range No. Fire No. County �(j�
EB•00001A-12 5/1999
TROY A
Addrgsg,�, S ��
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.. . . CA011�2
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npany or Owner Performing Installation) 1 '�-07'�i'Z f 612
: S. SAVAC'E. MN. 55378 �,� , �4 � ��
, Compan Pertorming Installation) hr• : r, �•:,A Phone Number
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TATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY