P - 81194E
" REQUEST FOR ELECTRICAL INSPECTION
' 0-854-619 [�4 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. Bldg. Other: New Addn
Commercial Industrial Farm Remod Repair
Air Conditioner 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 on/y.
NSP SAVER'S SVWTCH INSI'ALLATtON
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
Transformer/Generator
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
Fee - This
not be
0 to 200 Amps
Above 200 Amps
INSPECTOR'S USE ONLY
I hereby certliy that I inspected the
Rouah In
� � Investigative Fee � �
� � y v THIS INSTALLATION MAY BE
I IIIIII I�III IIII� I�III IIIII III��It �I) I�II
*08546194*
�ted without the correct fee.
# Circuits / Feeders
0 to 100 Amps
Above 100 Amps
TOTAL _
dates
( � I � ��w PZ_ I
tED DISC ECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 moMhs from validation date printed in this box.
� �G -�
7S�1�
Request Date Rough-In inspection required? ❑ Yes ❑ Inspection Other Than Rough�ln: ❑ Ready Now ��II Call
�,) � g You must call the inspector when ready� I Date Ready: �� ��
— --�
I, Q4icensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
�o�� �se�eec, �o '�� LN ft� c��' Ff�L?l.EY zip c 55@32
Sec[ion No. Township Name or No. Range No. Fire No. County �
-(Rr�.�r'►v� �'J�TEVEN M Phone No. [�+t211�—vJe�
l J
Powar.Supplier Addrg�, s �f�
IVS�" M.,4
Electrical Co�tractor / Com an Name Contrector License No. Master Lic. No. (PIaM Elect. Onty)
MA.SiFR ELE�C Ct3.. iRiC. C14011fl'2
Mailing Address (Contractor, Company or Owner Performing Installation) 8�2 �-07�� f Q�iZ �.�T
12467 � AVE S. BAVAGE. A�yV. 5�378 � � i �-
Authorized Signature (Contra ner P inq�lnstallatlon) Phone Number
I .. ,^ \ /
EB-00001A-12 5/1999 STATE BOARD COPY SEE INSTHUCTIONS ON BACK OF YELLOW COPY