P - 80775� � ,
= 0-854-589 �
N....
REQUEST FOR ELECTRICAL INSPECTION
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. Bldg. Other: New Addn
Commerciai Industriai 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 SWtTCH INSTALlAT10N
Calculate
Mobile Home Park Stall
Street Ltg./ Traffic Sig.
Transformer/Generator
Sign / Outline Ltg. Xfmr.
Alarm/Remote Conirol _
Fee - This Inspection Request will not be
�e # Service Entrance Size Fee
0 to 200 Amps 0 to 100 Ai
Above 200 Amps Above 100
INSPECTOR'S USE ONLY
correct
TOTAL ��
- —- I hereby certiry that I inspected the electrical installation described herein on the dates stated:
Irrigation Boom Rough In Date
j( Special Inspection 15.�)
Final Da
Investigative Fee � —
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
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OFFICE USE ONLY This request void 18 months from validation date printed in this box.
IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII�IIIIIII�I CJ�I.! �
* * �a3
08545899
Request Date Rough-In inspection required? ❑ Yes ❑ N Inspection Other Than Roug - n: ❑ Ready Now � Will Call
��2� You must call the inspector when ready� Date Ready: �
MfiAtlN
I, [j�icensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address (Streei, Box, or Route No.) Ciry ZP Ca1e:
OQOZ5 G�4RDENA lN f+� F'RIOLEY 5843Z
Section No. Township Name or No. Range No. Fire No. County Aw�yt �
/'yMln
STAIYTON O
P�pplier
� r` L.'
Electrical Gontrector / Com an Name Contractor License No. Master Lic. No. (PIaM Elect. Only)
�R �c%�c co.. ��c. eAO�i�
Mailing Address (Contractor, Company or Owner Performing Installation)
12487 BQUI� AVE S. , NNV. 5�378 i�'�2j941-0712 !(012�90-3:f85
Authorized Signature (Contractor, ortning Installation) Phone Number
�y �'73 51 c �
E&00001A•12 5/1999 STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY
Phone No. C812j671-05�1