P - 81166!
�-858-325 0
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REQUEST FOR ELECTRICAL INSPECT{ON
Minnesota State Board of Electricity
1821 University Avenue Suite 5-128, 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 Contlitioner 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'� SWITCH
Calculate Inspection Fee - This lnspection Request will not be accepted without the correct fee.
Installations Fee # Service Entrance Size Fee # Circuits / Feeders
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
TransformedGenerator
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
0 to 200 Amps 0 to 100 Ai
Above 200 Amps Above 100
INSPECTOR'S USE ONLY
S�
Irrigation Boom � hereby certity that I inspected the electrical installation described herein on the dates stated:
Rough In Date
Special Inspecti
Investigative Fee Fx,ei ,, o � Z s—
THIS INSTALLATION 1AAY BE ORDERED �.NNECTED IF NOT COMPLET�D WITH �J,��,��'�,,;�„
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OFFYCE USE ONLY This requeat vdd 18 months from validation date printed in this box.
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*08583254* �6�
PLEASE PRINT OR TY
Requg��t�� Rough-In inspection required? O Yes � No Inspection Other Than Rough-In: L7 Ready Now O Will Call
�� � a�� You must call the inspector when ready! Date Ready:
I, ❑ licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Add��et, Box, ��i�R Rt� °ity FRfDLEY Z�P �
Section No. Township Name or No. _Y Range No. Fire No. Count�a�
Occupant EADALBERT JA3C?N T Phone No. M�
Powep�jer Address ��
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Electriul �n_ _�raC; /CCo_m�n��am�RPORAI'I�N Contrador Licen�eflo+ ____ Master Lic. No. (Plant Elec[. Only)
„�,nn� ���c•rR GA 009$'.�
Mailing��s�t�ctcr�[4�y ���r Pe�l�tic�N � MN 5Ei114
II4JK1 VL
Authorized Signature (Contrector, Com ox•'OWp e�rtning In on) ��� Ph�� m��� �
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EB-00001A-12 5/1999 STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY