P - 82076REQUEST FOR ELECTRICAL INSPECTION
('�,_QG�_Q("{Q � Minnesota State Board of Electricity F:� _
�.r vJ Z,�UV 1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993
� (651) 642-0800 www.e/ectriciry.state.mn.us '�
x Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial 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 on/y.
N3R 3AVER'S 3WITCH
Calculate Inspection Fee - This Inspection Request will not be
�ther Installations Fee # Service Entrance Size Fee
Mobile Home Park Stall 0 to 200 Amps
Street Ltg. / Traffic Sig. Above 200 Amps
Transformer/Generaior INSPECTOR'S USE ONLY
Sign / Outline Lt . Xfmr.
Alarm/Remote n o ' ' �
Swimming Pool
I hereby
Irrigation Boom Rough In
Special Inspection
Investigative Fee ���
THIS INSTALLATION MAY BE ORDI
II�I�I IIIII (III� IIIII I�III IIIII�II� I�) III)
*08598039*
without the correct fee.
�ircuits / Feeders
0 to 100 Amps
Above 100 _ Amps
I insoected the electrical installation
TOTAL
..-�$:�"
ao_�a
Date
lED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request vad 18 months trom validation date printed in this box.
� d0 -5�
PLEASE PRINT OR TYP����
Request Date Rough-In inspection required? ❑ Yes � I� Inspection Other Than Rough-In: �leady Now � Will Call
���� Yau must call the inspector when ready! Date Ready:
I, g] licensed contractor ❑ company ❑ owner hereby request inspection of the above electricai work at:
Job Address (Street, Box, or Route No.) City �P ��e:
Section No. Township Name or No. Range No. Fire No. County �
--'-"-- '--- -.-�_._..._.� �----"'-" � .
Occupant Phone No.
MISKOWIEC JC)HW W --_
Power Supplier Address
NSP ;G� � � �j ' ...___�
Electrical Contractor / Company Name Contractor License No. Master Lic. No. (Plant Elect. Only)
Mailing Address (Contrector, Company or Owner Performing Installation)
Z300 TERRI'TORIAL ROAD SAINIT RAUL MM 55'114
Authorized Signature (Contractor, Company or Owner Pertormingynstal{ation) Phone Number
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EB-00001A-12 5/7999 STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY