P - 81196' REQUEST FOR ELECTRICAL INSPECTION
• O_854'�`3� � Minnesata 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. Bldg. Other: New Addn
Commercial Industrial 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 on/y.
NSP SAVER'S S'�MTCN II�Si'ALlAT10N
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee.
�ther Installations Fee # Service Entrance Size Fee # Cirouits / Feeders
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg. / Traffic Sig. Above 200 Amps Above 100 Amp�
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
Swimmin
I hereby certify that I inspected the electrical installation described herein on the da1
Irrigation 00 Rouqh Ir� Date
JC Special Inspection � �'� �
Final Date
Investigative Fee Z—/ Z –o %
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
, --- - Y.W...»...Y............,.._........._,..»._w.......»........» ....................................._........
OFRCE U8E ONLY This request void 18 monlhs from validation date printed in this box.
illlllllilllllli1111llllll1111 Iill�� � • �°-�
�
*08546301 * ���
PL �J9QQOOQQ
Fiequest Date Rough-In inspection required? ❑ Yes ❑ Inspection Other Than Rough�ln: ❑ Ready Now � Will Call
�,�� You must call the inspector when ready� Date Ready: � ��'�
�n.r.:..�
I, []6icensed contraetor ❑ company ❑ owner hereby request inspection of the above e{ectrical work at:
Jo� (Street, Qpu,,,pt �p�,�,p�o,j„� � City ��EY Zp Co '.�: �
Mt„71�i[]t ti t
Sectian No. Township Name or No. Range Na. Fire No. County J�[�(A
CR�UG J
(692�74-Z530
Po�NYr.6uDplier Addrg�� � ���
IY7P" {YR'L
e i�gpj�a�r /f��jart�g^.• ,�• ContractoLLice"n��� Master Lic. No. (PIaM Elect. Only)
"{tt�� t-� E- [: t:��� CAv
9�2dB7 BS �cOQ(+fE AVE 5, ��4VeAC�, ���1� �5�3�8 i�12�41-4712 /(li12jB80-3555
Authorized Signature (Contract ner Performing IrySpl r�,�„ Phone Number
^'� �'S�A.. ( )
EB-00001A-12 5/1999 STATE BOARD COPY SEE JNSTRUCTIONS ON BACK OF YEL�OW COPY