P - 80805.4-854-634 0
REQUEST FOR ELECTRICAL INSPECTION �" E'
Minnesota State Board of Electricity `•�
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 -_ -
(651) 642-0800 www.e/ectricity.sfate.mn.us . �
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Repair
Air Conditioner Htg. Equip. Water Htr. X 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.
N5P SAVEFt'S SIMTCH INSTALtATiON
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
Transformer/Generator
Siqn / Outline Lta. Xfmr.
Fee - This Insvection Reauest will not be
0 to 200 Amps
Above 200 Amps
INSPECTOR'S USE ONLY
without the
Circuits / Fee
0 to 100 Ar
Above 100
fee.
TOTAL
- I hereb certi that I inspected the electrical installation described herein on the dates stated:
Irrigation Boom Rough In Date
X Special Inspection iS.�
Investigative Fee F�"�� oate��, ��� g
r
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
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OFFlCE USE ONLY This request void 18 months from validation date printed in this box.
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Request Date Rough-In inspection required? ❑ Yes ❑ Inspection Other Than Roug111n: � Ready Now ❑ Will Call
You must call the inspector when ready� Date Ready: ��
I, [jdicensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Joj�gdQrg� (Street, or R te o �� Ciry ���EY Zip Code:
WQ4 55d32
Section No. Township Name or No. Range No. Fire No. County �
Authorized Signature
EB-00001A-12 5/1999
�� D rnone rvo. �81n�71�71�� .
6
AddrgsS,,, C''J QF��
iYR�L
am Contractor License No. Master Lic. No. (Plant Elec[. Only)
� G�O., tNC. CA01lp2
or, Company or Owner Performing Installation)
AVE S. �►VAGE. MN. 56378 (81Zj941-4712! (812�-3�
itr er Perfort�ng Installation) �hrnre Number
__ �► 7 i
TATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY