P - 81075E
REQUEST FOR ELECTRICAL INSPECTION •
- 4-858-343 [7] Minnesota State Board of Electricity F;-
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. Loatl Mgmt. Other:
Dryer Range Elect. Heat Temp. Service
'X" above the work covered by this request. Enfer remarks in this space and on the back of the white copy on/y.
NSR 3AVER'S SWITCH
Calculate Inspectic
�ther Installations
Mobile Home Park Stail
Street Ltg. / Traffic Sig.
Transformer/Generator
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
Swimmina Pool
Fee - This
noi be
0 to 200 Amps
Above 200 Amps
INSPECTOR'S USE ONLY
1 herebvi certiN that I inspected the
�ted without the correct fee.
# Cirouits / Feeders F
0 to 100 Amps
Above 100 Amps
TQ�^
on the dates stated:
- - Final / � �j� .,. ..._.__ �. Date % C� Z
Investigative Fee � �— %—
THIS INSTALLATION MAY BE ORDERED DIS ECTED IF NOT COMPLETED WITHIN 18 MONTHS.
_._..__._._.�.___°__��_____�_.......� ............................. ...............�.�,.....,...................�.........�m,....m,..,� .
OFFICE USE ONLY This request void 18 monfhs fro�;vatidatlon date printed in this box.
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*08583437* ���
PLEASE PRINT OR i'Y
Re�ug� C�t�� Raugh-In inspection required? � Yes ❑ No Inspection Other Than Rough-In: � Ready Now ❑ Will Call
+ 7a�� You must call the inspector when ready! Date Ready:
I, ❑ licensed contractor ❑ company ❑ owner hereby request inspection of the above electricaf work at:
Job AddrASRfSiCeet, eoX, ��E C�R ME c��' l�RIDLEY Z�p �3Z
riL04
Section No. Township Name or No.� Range No. Fire No._.�«, CounM►�I1� '
'-- "" -- '— 111�y
OccuPant PETER30N D1ANE M Phwre No. �_..
Powe�ier Address M.���
Electri / a Contractor Lice e Master Lic. No. (Plant Elect. Only)
F� ����� �ORP�RATt4N ��0883
neailin�r ����y��i�pe��t�� MN 5511�
Authorized Signature (Contractor, Company or Owner Performing In ion) +!�y� Phone Number
f�l ,.o.;r �..,.. �� . ��'V�'�`ir� ( �.l� �B–�'�
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EB-00001A-12 5/1999 STATE gOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY