P - 83603IIIII) IIIII IIII� IIIII IIIII IIIII IIIII IIII) (III (III
*03922978*
REQUEST FOR ELECTRICAL INSPECTION ���
Minnesota State Board of Electricity ��,.�4 °'"
1821 University Ave., Rm. S-128, St. Paul, MN 55104 a�. ,,�
Phone (612) 642-0800 �'�`T�
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Repair
Air Cond. Htg. Equip. Water Htr. }{ Load Mgmt. Other:
Dryer Range Elec. Heat emp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the white cqoy only.
SAVER'S SWITC:H INSTALLRTION
Calculate Inspection Fee - This Inspectiar Request will not be accepted without the conect fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLV TOTAL
Sign/Outline Ltg. Xfmr. . S0
Alarm/Remote Control
Swimming Po I he2by certiry that I inspected the electrical installation described herein on the dates stated
Irrigation Boom Rough-In Date
X Speciallnspection 1 . 50
Final Date/� ZZ — �}G'
Investigative Fee l 7l
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validation date printed in this box.
392-297 � � �
la�
JOB NUMBER �t9806000
PLEASE PRINT OR TYPE
Reque,�t.t�ats� ���� Rough-in inspection required? ❑ Yes ❑�lo Inspection Other Than Rough-In: fi, Ready Now ❑ Will Call
1 ! '7[
(You mus[ call the inspector when ready) Date Ready:
I, � licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Street, Box, or Route No.) City Zip Code
Q111Qt0 GARDEHA AVE HE FRIDLEY 55432
Section No. Township Name or No. Range No. Fire No. Counry
ANOKA
Occupant Phone No.
ROBERT J BURNHAM 340-7237
Power Supplier Address
Electrical Contractor (Company Name) Contractor License No. Master Lic. No. (Plant Elect. Ony)
Mailing Address (Contractor or Owner Performing Inst ation)
Authorized i nature (Contractor or Owner P�rry�ry�tio�� �� ��
�� �� U
EB-00001A-11 S/95 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY