P - 80762, REQUEST FOR ELECTRICAL INSPECTION
I''1_Q�/� _�(�� � Minnesota State Board of Electricity _ _
�.J U—r U 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 Industrial Farm Remod Repair
Air Conditioner Htg. Equip. Water Htr. Loatl 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 the whlte copy onry.
P6SP SAVER'S SYWTCH iMS'T'ALLATION
Calculate Inspecti�
Jther Installations
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
Transformer/Generator
Sign / Outline Ltg. Xfmr.
Alarm/Remote �pp�rQl_
BOOfII
Fee - This Inspection Request will not be accepted without the
�e # Service Entrance Size Fee # Circuits / Fee
0 to 200 Amps 0 to 100 Ar
Above 200 Amps Above 100
INSPECTOR'S USE ONLY
I herebvi certiiv that I insoected the electrical installation described hi
Date
tee.
statetl:
rmei
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 montl�s from validation date printed in this box.
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Request Date Rough-In inspection required? � Yes ❑}�' Inspection Other Than Rough�n: � Ready Now ❑ Will Call
�1� You must call the inspector when ready1.r' Date Ready: ��
I, [�9icensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
�o�� �st�aat, �`A�� AVE !t� °i�' FRtt)l.EY �P ���Sq3
Section No. Township Name or No. Ra�ge No. Fire No. County A�(x,(0
CQUN T
"°. (B1�j�7d-63Z0
�, Pq�{@r,$ppplier Addr s
fV�" �c.s o�tcE
Electrical Contractor / Com any Name Contractor License No. Master Lic. No. (PIaM Elect. Onty)
awsrER �c�c co.. �NC. cAO���
Mailing Address (Contractor, Company ar Owner Performing Installation)
7Z487 Bt30iVE AVE S, SAVAGE, MN. 53378 (012j941-0712 !(612j8�3-3$$�
Authorized Signature (Contracto wner Performing Instal (� � Phone Number
u � �
EB-OOOOtA-12 5/1999 STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY