P - 81201��
- Q-854-627
❑ REQUEST FOR ELECTRICAL INSPECTION
'7 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. Bidg. 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.
NSP SAVER'S SVIATCH INSTALLAT'rON
Calculate Inspection Fee - This Inspection Revuest will not be accepted without the correct fee.
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
TransformedGenerator
Sign / Outline Ltg. Xfmr.
0 to 200 Amps 0 to 100 Ai
Above 200 Amps Above 100
INSPECTOR'S USE ONLY
TOTAL
I�fl dtlOfl BOOhI 1 hereb cert' that I inspected the electrical installaGon described herein on the dates stated:
g Rough In Date
X Special Inspection 1�1
Final , Date
Investigative Fee " � � �1— ��
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
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� WOFFlCE USE ONLY This request vad 18 months from validation date printed in this bax.
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P��16BPAl1�N+A6ER�f�908000
Request Date Raugh-In inspection required? � Yes ❑ Inspection Other Than Rough�n: ❑ Ready Now ❑ Will Call
�,�.)� You must call the inspector when ready� Date Ready: J1 ,_ ___ �_
I, [a9icensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Johec�ly�s (Street, �„qr� el� � City ��Y
tr.�aar ��
Section No. Township Name or No. Range No. Fire No. Cw
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P ^ pplier Addr�s�, S �F� +�
IV:N" NR�L
ta1��� ��a
Electrical Contractor / Com an Name Contractor License No. Master Lic. No. (Plant Elect. Onty)
M� �ci�c co., inic. cRO��ez
Mailing Address (Contractor, Company or Owner Performing Installation) �12 1-0712 ! Q72
��ae� ec�orvE avE s, sav�. �v. �, t� t�a-�
Authorized Signature (Contractor, PeAormin a Phone Number
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EB-00001A-12 5/1999 STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY