P - 80769E
� REQUEST FOR ELECTRICAL INSPECTION
.-0-854-595 �6 Minnesota State Board of Electricity -
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993
� (651) 642-0800 www.electricity.state.mn.us
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial 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 on/y.
IVSP SAVER'S SYVITCH INSFALLAl10N
Ca/cu/ate Inspection Fee - This Inspection Repuest will not be accepted without the correct
Mobile Home Park Stall
Street Lig. / Traffic Sig.
TransformedGenerator
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
0 to 200 Amps
Above 200 Amps
INSPECTOR'S USE ONLY
'�� Rough In
0 to 100 Ai
Above 100
TOTAL �"�
Date
stated:
� � Investigative Fee � �'"'�' �����. �"��� �/(�� Z-- �
� �, �.�. THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
Yu.�. V Y W W�wW W� W���� Wy.4W �~�OFFICE USE ONLY This request vad 18 months from validation date printed in this box.
I IIIIII IIIII IIIII IIIII IIII) IIIII �II IIII (III ���
*08545956* �a3
Aequest Date Rou h-In ins ection r uired� ❑ Yes ❑� Ins g-: dy
g p eq . pection Other Than Rou 71n ❑ Rea Now ❑�II Call
� f,�,�� You must call the inspector when rea Date Ready: 1� __
I, [�icensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address (Street, Box, or Route No.) City Zip Code:
�2�4 U�tTf' ST i� ��-�' S'3�32
Section No. Township Name or No. Range No. Fire No. County AA��
�Ri►v+
OPCYRSWi+. r�uA Phone No.
�rVbbrw ��Y K (812)783-7T75
P�PPlier Addre.s�sy /�C
fYR�Ls 4T� r�
Electrical Contractor / Company Name Contractor License No. Master Lic. No. (Plant Elec
Masr� �cn�c co., uvc. cao���
Mailing Address (Contractor, Company or Owner Pertorming Installation)
12d67 8001� AVE S. SAVAQE, i�l. 55378 (B17jli4'I-+l7t21 (612�0--3'.�5
Authorized Signature (Contractor, Company ar Owner Perfortning Installation) Phone Number
\ /
EB-00001A-12 5/1999 STATE BOARD COP SEE INSTRUCTIONS ON BACK OF YELLOW COPY