P - 80764REQUEST FOR ELECTRICAL INSPECTION
4-854—VOO � Minnesota State Board of Electricity _
1821 University Avenue Suite 5-128, 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 only.
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Calcu/ate Inspection Fee - This Inspection Request will not be accepted without the correct fee.
nstallations Fee # Service Entrance Size Fee # Circuits / Feeders
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
Transformer/Generator
Sign / Outline Ltg. Xfmr.
Alarm/Remote Cy�Tj� �
Swimming Pool �
Irriaation Boom
0 to 200 Amps 0 to 100 Amps
Above 200 Amps Above 100 Amps
INSPECTOR'S USE ONLY TOTAL ,�,��„'
I hereby certiy that I ins ed the electrical installation described herein on the dates stated:
Rough In Date
� � Investigative Fee � �"' ���" — — ��'� ,j -� o r I
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
� OFFICE �USE ONLY This request void 18 months from validatlon date printed in this box��
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08546004
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Request Date Rough-In inspection required? ❑ Yes ❑ yp Inspection Other Than Rougldn: ❑ Ready Now � Will Call
(� j�7�p You must call the inspector when readyf ti Date Ready: �� b j�^�y,�
I, [�Qicensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Jo�j.�l[2� (Street, �r,@q�j��j�p��, � � City ��Y Z�P C ��
tJ 10 ( Uf�iJUtAV
Sedion No. Township Name or No. Range No. Fire No. CouMy �j[�
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(612)750-�4
Pqyy�,Fypplier Addrgs�„ S � �
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Electrical Contractor / Com an Name Contrector License No. Master Lic. No. (Plant Elect. Only)
k1+4STER ELEC�G Ct).. INC. CA01192
9����87f8�c8401tVE`AVES. �w7�'1VAIPerformit�Mi.sfi5378 (013j941-07'IZ! (012j8�}-3$55
Authorized Signature (Contractor, C ner PerfortninglPr�llation) Phone � mber
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EB-00001A-12 5/1999 STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY