P - 81195' REQUEST FOR ELECTRICAL INSPECTION
"� Q-854-616 ❑0 Minnesota State Bo�rd of Electricity -
1821 University Avenua �uite S-128, Saint Paul, Minnesota 55104-2993
(651) 642-0800 www.elecfricity.state.mn.us
Home Duplex Apt. Bldg. Other: New Adtln
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.
n� sAV�s s�n-rcH in�;rau.A►nav
Ca/cu/ate Inspecti�
Other Installations
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
Transformer/Generator
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
Irrigation Boom
Special Inspect
Fee - This Inspection Request will not be
>e # Service Entrance Size Fee
0 to 200 Amps
Above 200 Amps
INSPECTOR'S USE ONLY
without the correct fee.
Circuits / Feeders
0 to 100 Amps
Above 100 Amps
TOTAL �
y certify that I inspected the electrical installation described herein on the dates stated:
In Date
9 Final ��_ I Date� ��Cj.� I
Investi ative Fee �—
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
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............................ ..........._._.-
OFFICE'J1SE ONLY This request vdd 18 monthsrrom validation date priMed in this box.
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Request Date Rough-In inspection required? ❑ Yes ❑ Inspection Other Than RougF�n: � Ready Now � Will Call
�,�� You must call the inspector when ready1.� Date Ready: ��
I, []Gicensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
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Section No. Township Name or No. Range No. Fire No. County �(�(A
Mailin Address (Contractor, Company
�z�a� Boar� AvE s,
Authorized Signature (Contractor, Co �
1:�=I
Phone No. tg,��t7ne Anf�
� � Oiti�V
Add IYR�L.�1 Vf"r��rG
,'s�. Contractor L�cc���� Master Lic. No. (Plant Elect. Only)
I�M1i ���
Dwner Performin Installation)
�v�. r�v. ��� t��a�aa�-a��z r �8�a�u-�
r Performing t�ti Phone Number
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E&00001A-12 5/1999 ,�STATE BOARD COPY SEE INSTRUC710NS ON BACK OF YELLOW COPY