P - 80776t:-- -
� REQUEST FOR ELECTRICAL INSPECTION
'Q_$�4_588 � 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. Bltlg. 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 of the white copy on/y.
WSP SAVER`S �WITCH INSTALLA710N
Ca/culate Inspection Fee - This Inspection Request wil/ not be accepted without the
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
Transformer/Generator
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control_
irrigation Boom
0 to 200 Amps 0 to 1Q0 Amps
Above 200 Amps Above 100 Am�
INSPECTOR'S USE ONLY TOTAL
In
that I insoected the electrical installation described herein on the dates stated:
Investigative Fee F�� ��__��� - I D�/ 2 G r o% I
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
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OFFICE USE ONLY This request void 18 moMhs (rom validation date printed in this box.
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Request Date Rough-In inspection required? � Yes 0 No Inspection Other Than Rough-In: � Ready Now O WNI Call
M.��M� You must call the inspector when ready� Date Ready: x
I, [�licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address (Street, B`o.x,wo�r Rout/e yN�o'.) Ciry �� Zp Code:
�' w�Y.�SV1� ,J� � JW.�
Section No. Township Name or No. Range No. Fire No. Counry wwyyt�
/'YR�IV'�
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P�pplier Address
t1APl..g
Electrical Contractor / Com n Name
h�i�5'�R F1.EC�� C{3.. il�iC.
Mailing Address (Contractor, Company or Owner Performing Installation)
1Z487 BaOPiE AVE S. SAV�CE. MW. �3�1
Authorized Signature (Contractor, —_ wner Perforining Ins
EB-00001A-12 5/1999 ��STATE BOARD COPY
Phone No.
OFFI CE
Contractar License No.
CAOi 992
t�� �� ��
Master Lic. No. (PIaM Elect. Onty)
{81Zj944-0712! (Q12�9t1-35�5
Phone Number
l 1
SEE INSTFiUCTIONS ON BACK OF YELLOW CAPY