P - 80772F
� REQUEST FOR ELECTRICAL INSPECTION
�-854-592 03 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 onty.
NSP SAVEi�'S SWITCH INSTALLRTiON
Ca/culate Inspection Fee - This Inspection Reauest will not be
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
TransformedGenerator
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
0 to 200 Amps
Above 200 Amps
INSPECTOR'S USE ONLY
without the correct fee.
Circuits / Feeders
0 to 100 Amps
Above 100 Amps
TOTAL �
Irrigation I hereb cerdiy that I inspected the electrical installation described herein on Me dates stated:
Rough In Date
x Special Inspection 15.50
Investigative Fee � �a�2_Z—� —o
. �THIS INSTALLATION MAY BE ORDERED DISC NECTED IF NOT COMPLETED WITHIN 18 MONTHS.
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OFFlCE USE ONLY This request void 18 montlis from validation date printed in this box.
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Request Date Rou h-In ins ection r uired? ❑ Yes ❑ Ins
g p eq pection Other Than RougFlyi: ❑ Ready Now ❑ Wil� Call
� fq.�� You must call the inspector when ready� � Date Ready: � �ti ___ _ �_
I, [jQicensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Jojtg���s (Street, �Q� �` � �ily ��Y Zip Code:
� �s a �.�t 55432
Section No. Township Name or No. Range No. Fire No. Counry �A
� FRED M
PQ�,�PPlier
�Yar
E�le�ct�nc�al Gonptrec�tryor / cC�o+m�pany� ^Name �y�
RM'M7�6.R GI.G4r 1l�I`r C�., i�Y6r.
Mailing Address (Contractor, Company or Owner Pe
1Zd67 BC)OrE AVE S.
Authorized Signature (Contract or Own
EB-00001A-12 5/1999
Phone No. �a����—,yl�
V �7V
Addr�s ��'�
Contractor License No. Master Lic. No. (Ptant Elect. Onty)
cAO��az
ing Installation)
�r6V. �{'i378 (812j941-d7121 (012�f3-3555
rforming Installation) Phone Number
� \ /
STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY'