P - 80306� REQUEST FOR ELECTRICAL INSPECTION ' E
• 4-853—�OG � Minnesota State Board of Electricity
1821 Universiry Avenue Suite S-128, Saint Paul, Minnesota 55104-2993
(651) 642-0800 www.electricity.state.mn.us � r '
Home Dupiex 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 of the white copy only.
Ca/culate
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
Transformer/Generator
Sign / Outline Ltg. Xfmr.
Irrigation Boom
NSP SAVER`5 SVI�TCH INSTALLAl10N
Fee - This Inspection Request will not be accepted without the correct fee.
:e # Service Entrance Size Fee # Circuits / Feeders Fee
0 to 200 Amps 0 to 100 Amps
Above 200 Amps Above 100 Amps
INSPECTOR'S USE ONLY TOTAL
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I herebvi certitv that I inscected the electrical installation described herein on the dates sta
x Special Inspection 2p.�
Investigative Fee Final Dateiia//. 2�^�
/
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
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OFFICE USE ONLY This request vad 18 moMhs from validation date printed in this box.
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*08530024* �7�
PLEASE PRINT OR TYPE
Request Date Rough-In inspection required?�7 Yes O No Inspection Other Than Rough-In: Ready Now ❑ Will Call
'��f2��� You must call the inspector when ready! Date Ready: '��7f�Q
I, � licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sheet, Box, or Route No.) City Zip Code:
Oi]112 GIBRA{..TAR RD FRIDLEY �5421
Section No. Township Name or No. Range No. Fire No. Counry
Occupant Phone No.
RYMWN JOSEPN (612j574-0987
Power Supplier Address
�p MPLS OFFI CE
Electrical Contractor / Company Name Contractor License No. Master Lic. No. (Plant Elect. Only)
MA,�'TER ELECTRIC CO., INC. CAQ1192
Mailing Address (Contractor, Company ar Owner Perfortning Installation)
12Q87 B�ONE AVE S, SAVAGE, MN, 55878 (8'12)941-�3712 (612�L�355
A Signature (Contractor, Cop�p�Or Pertorming Installation) �hone Number
�G 9 1
EB-p0001A-12 5/1999 STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY