P - 80790f
, Q-854-651
❑ REQUEST FOR ELECTRICAL INSPECTION
7 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 Intlustrial Farm Remod Repair
Air Conditioner Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Efect. 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.
N5P $AVER'S SIMTCH I1�1"ALLATiON
Ca/cu/ate Inspection Fee - This Inspection Request will not be accepted without the correct fee.
Other Installations Fee # Service Entrance Size Fee # Circuits / Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg. / Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign / Outline Ltg. Xfmr. � �S
Alarm/Remote C trol
Swimming Poo!
If1'i BtiOn BOOfTI I hereb certity that I inspected the electrical installation described herein on the dates stated:
g Rough In Date
x Special Inspection 15.�
Investigative Fee Final , �a l, � o� f
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
. .........._.......�._.__..,,........._._.........._......- ..........:........_:...�_:T �.......,...._..�......�:... P
OFFICE USE ONLY This uest vad 18 months from validation date rinted in this box.
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Request Date Rough-In inspection required? ❑ Yes ❑ Inspection Other Than RougF�n: ❑ Ready Now ❑ WII Call
�q7� You must call the inspector when ready� Date Ready: � ��„ _,�
I, []4icensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Jobp�re� (Street, Qox,..�ite,plq�„� � � I c�ty �p�EY
taall NIR Kt'lU
Section No. Township Name or No. Range No. Fire No. Cc
Pou��6upplier
IY..'N�
DUNALD M ,"
AddrQ�g.,. S, �� r�
P�R'L
Ry► Contracto�r+.License Nryo.�
�•, �1`i{.�. `ri�1��117i
Mailing Address (Contractor, Company or
1za�7 eotx� avE s, s
Authorized Signature (Contrector, Compa�
Installatlon)
i. 5�378
EB-00001A-12 5/1999 //�'fATE BOARD COPY
(812�A1-tl7121 �812�-3535
Phone Number
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SEE INSTRUCTIONS ON BACK OF YELLOW COPY