P - 81608�j O�1 G''7�O (n I REQUEST FOR ELECTRICAL INSPECTION �"' E'
� � V � �� Minnesota State Board of Electricity �
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 -- -
(651) 642-0800 www.electriciry.state.mn.us �- '
Home Duplex Apt. Bldg. Other: New Addn
Commercial Intlustrial 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 ot tne wn�te copy onry.
f�tSF°' '� .AV�R';a :;dVi'1"t:_i-f 1P�a��AI..L.�ll'I::'3N
Ca/culate Inspecti<
�ther Installations
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
TransformedGenerator
Sign / Outline Ltg. Xfmr.
� Pool
BOOm
- This Inspection Request wil/ not be
# Service Entrance Size Fee
0 to 200 Amps
Above 200 Amps
INSPECTOR'S USE ONLY
THIS
. I IIIIII IIIII IIIII IIIII (IIII IIII IIII) IIII IIII
�1016 00*
that I inspected the
without fhe correct fee.
�ircuits / Feeders Fee
0 to 100 Amps
Above 100 Amps
TOTAL
2p.50
herein on the dates stated:
��. ��----- � oeta� � _ z. z -� �
NOT COMPLETED WITHI�J�'j$�$��^�
. . ....r. �.... ...�,....,.....,.,..�.. y,....:u ...................................,
OFFICE USE ONLY 7Ais requ�t void 18 moMhs from validation date printed in this box.
� 1 `� �� _/{1..���EAe'����4 �Q{����}Q
1 -�„
�' PLEASE PRINT OR TYPE
Re uest Date
����.�� j�� Rough-In inspection required? � Yes ❑ No Inspection Other Than Rough`In: ❑ Re�ry�v�Q.�ll Call
You must call the inspector when ready! Date Ready: fJ��� �•�f�l
I, �censed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address (Street, Box, or Route No.) Ciry Zip Code:
C1529#3 F=1LLM�RE 5T NE FR(dLEY �v�i21
Section No. Township Name or No. Range No. Fire No. County
/�t}�(jdi
Occupant Phone No.
SKOVRAN -ri-�r��,hec Flr�yn� f7�3)57�-8522
Power Supplier Address
��� 2 8 � 6 � ���� ���� ��
Electrical Contractor / Company Name Contractor License No. Master Lic. No. (Plant Elect. Only)
�Vir�r'.�' �� �i..����� {.'• fi{a. � t ��. �Id1Q'{ `� ��,
Mailing Address (Contractor, Company or Owner Perfortning Installation)
BC�C�NE AVE � SAV.ACE MiV 55378 (?ts�jd4�3-003�I(4�5�jt�i�t7-35�a�v
uth ' e ' nature (Contractor, Company or Owner Perfortning Installation) Phone Number
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EB-00001A- 5/1999 STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY