P - 81202. � 0-854-618 []6
REQUEST FOR ELECTRICAL INSPECTION
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. Bidg. 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 tne bacK ot tne wnire copy onry.
NSP SAVER'S S1M'FCH IN5T'ALi.A�14N
Calculate Inspection Fee - This Inspection Request will not he accepted without the correct fee.
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
TransformeNGenerator
Sign / Outline Ltg. Xfmr.
Boom
0 to 200 Amps
Above 200 Amps
INSPECTOR'S USE ONLY
t hereby certifv that I
0 to 100 Amps
Above 100 Amps
TOTAL ��
o"ZD •�
described herein on
Investigative Fee F��� (� ����-�'�'— ���'�� �� �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months trom validation date printed in this box.
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Request Date Rough-In inspection required? O Yes ❑ I�p Inspection Other Than Rouglxn: O Ready Now ��tl Cali
�1 � You must call the inspector when readyf � Date Ready:
I, []Cicensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
J�i��f� �s"��� �`C�� CtJRVE °iry F'RIDl.EY Z�P �' �55432
Section No. Township Name or No. Range No. Fire No. Counry �
91�Y4�lft�MA IIIMCHAEL. .) Phone No. tS'i•�j%v:J�'Id�
P�PPiier Addr�S ���
Electrical Contractor / Com an Name Contractor License No. Master Lic. No. (Plant Elect. Ony)
i,MwTER ELEC�C CO., INC. CA01792
9�Z467'eSSBC)OIVE AVE S. �SAVAGE ��I�I��enet� 7S ($12�41-4712 ! (�12}89L3-3�35
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Authorized Signature (C or, Company o orm' n I t r� f:� Phone Number
_ - � �
EB-00001A-12 5/19 STATE BOARD COPY � SEE INSTRUCTIONS ON BACK OF YELLOW COPY�