P - 81176F
REQUEST FOR ELECTRICAL INSPECTION
V` '858_32Q a Minnesota State Board of Electricity _
v 1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993
(651) 642-0800 www.electricity.stafe.mn.us :
Home Duplex Apt. Bldg. Other: New Adtln
Commerciai Industriai 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.
N3P SAVER'3 SWITCH
Calculate
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
Transformer/Generator
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
Fee -
will not be accepted without the correct fee.
0 to 200 Amps 0 to 100 Amps
Above 200 Amps Above 100 Amps
INSPECTOR'S USE ONLY TQ,���-y
of�. �
I hereby certify that I inspected the electrical installadon described herein on the dates stated:
Rough In Date
� � Investigative Fee � � ��� � �_ f ��- C��
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
._...... ....................................................�...........,.,.,,.....,K,.,..-.,,,.....,...... P
"`�-�--�' ""�"��F�i�E �E �n1:iT� Tfiis �uest vaa 18 monihs from validatian date nnted in this box.
1111NIiIIIiIIIIIIIIIiIIIIIIIiIII�II�IIN1l�ll � �°.�
*08583296* 76�
PLEASE PRINT OR TY
Regu�st�tg,_ Rough-In inspection required4 ❑ Yes � No Inspection Other Than Rough-In: � Ready Now [7 Will Call
�' /��laH You must call the ins
pector when ready! Date Ready:
I, ❑ licensed contraetor ❑ company ❑ owner hereby request inspeclion of the above efectrical work at:
Job Addr��j�eet, Box, yS[ip�i►q���� �" "C City �p'�� Zip �M
arf4� SrrIZCh7 i G IY I�G R J"+�4JL
Section No. Township Name or No.��� Range No. Fire No. Countut r�/ti�
.Y �_ 2'11�V
Occupant `►uL�'� l�� L Phone No. _____
Powe�elier Address w___�_.r
I�f 7�'
Electrj�p( �op������,�lag���RAT14N Contractor Licer�geflg��� Master Lic. No. (Plant Elect. Only)
N�JN 1 G 4U�� G� A ��troo3
""e���"�Sf'�'�`'i`�`ci�E9�CY REf�iPe'��i9�'i''�"i�'1i'L, MN 55114
Authorized Signature (Contractor, C er. erforming In on) ��� �ho�Num����
,�
EB-00001A-12 5/1999 STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY