P - 822401_�-� �'n'7� � REQUEST FOR ELECTRICAL INSPECTION E
, G� 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. Bidg. 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 only.
NSP SAVER'S SWITCH
Ca/cu/ate 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/Generator INSPECTOR'S USE ONLY
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
I hereby certiy that I inspected the electri
Irrigation Boom Rough In
I I Investigative Fee I I
.. . .THIS INSTALLATION MAY BE ORDERED
I��I�I��I�I�����II�����I�I�I� �� _._.�
*10152 8*
without the crorrect fee.
�ircuits / Feeders
0 to 100 Amps
Above 100 Amps
TOTAL
�.�
Date
�.�.�--- I �- 2- �- �'/ I
ED IF NOT COMPLETED WITHIN 18 MONTHS.
...........�...... ..................................................... . ...
request vad 18 months from validation date printed in this box.
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PLEASE PRINT OR TYPE
Request Date Rough-In inspection required? ❑ Yes ❑ o Inspection Other Than Rough-In: Ready Now 0 Will Call
� 1�,�� You must call the inspector when readyl Date Ready:
I, Q9icensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address (Street, Box, or Route No.) Ciry Zip Code:
625t i�RRY W NE FRIDtEY 56�13�
Section No. Township Name or No. Range No. Fire No. Cou�nty���y�
' I'�i
Occupant Phone No.
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Power Supplier Address
NSP
Elec[rical Contractor / Company Name Contractor License No. Master Lic. No. (PIaM Elect. Onty)
Hur� E�crnic coR�naN c�► ooae�
Mailing Address (Contractor, Company or Owner Perfortning Installation)
2300 TERRITORM1i IRQAd ,�INT PAUL, R�i 6611 �
Authorized Signature (Contractor, Company or Owner Performing Instailatlon) Phone Number
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EB-00001A-12 5/1999 STATE BOARD COPY � SEE INSTRUCTIONS ON BACK OF YELLOW CAPY