P - 81609, � �`-016-745 OQ
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REQUEST FOR ELECTRICAL INSPECTION ; —
Minnesota State Board of Electricity F:- _ 'g
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 = -
(651) 642-0800 www.electricity.state.mn.us :�:'
Home Duplex Apt. Bldg. Other: New Atldn
Commercial Intlustrial 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.
iJBi�' ;:.�.���J�:�°i; ;��"vt i�f�:i--I iTV:�I`.�ki,..Lrtil>��f`v`
Ca/cu/ate Inspecti�
�ther Installations
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
Transformer/Generator
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
Fee
Fee - This Inspection Repuest will not be
0 to 200 Amps
Above 200 Amps
INSPECTOR'S USE ONLY
Final
without the correct fee.
�ircuits / Feeders
0 to 100 Amps
Above 100 Amps
TOTAL
I inscected the electrical installation described herein on the dates stated:
I °�-- `Z3 ' �'i I
IF NOT COMP� WITHIN„j,g .................:W�.
�B 18 months from validation date printed in this box.
_ - -� --- .. . . . /
* 1 � � . 6 % 0 * l V �% i� �� ,.��; '��.��� � ����;���
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PLEASE PRINT OR TYPE
Request Date y
��������.� Rough-In inspection required? � Yes ❑ Inspection Other Than Roughqh: ❑ Ready Now ❑ Will Call
You must call the inspector when readyl Date Ready: ���Q�IQQ
I, [�I censed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address (Street, Box, or Route No.) �i�, Zip Code:
OC19'�2 PiL�ii`A�E FRIC}L�Y �5ct�1
Section No. Township Name ar No. Range No. Fire No. County
JERCatvi� A
� ""`- - — -- ." " MPLS OFFi C:E
lectrical Contractor / Company Name Contractor L
M1A�7FF2 FI_FC:Tfi�tf' t;'C7 : il�I('. C.
ailing Address (Contractor, Company or Owner Performing Installation)
12�iB7 I�C3QNE AVE S, �.AVf�GE: Ar1N, ��5:�7�
or' �fgnature (Contractor, Company or Owner Performina Ins�anafinni
EB-00001A=i�5/lggg STATE BOARD COPY
���
�B'12j5i4-268f3
No. Master Lic. No. (Plant Elect. Onty)
1 �32
( 7fi� }d �3-t�t739�`( 8�2 j89tk-3555
Phone Number
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SEE INSTRUCTIONS ON BACK OF YELLOW COPY