P - 81193REQUEST FOR ELECTRICAL INSPECTION
�t�-854-612 90 Minnesota State Board of Electricity
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 Addn
Commercial Industrial Farm Remod Repair
Air Contlitioner Htg. Equip. Water Htr. Loatl 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 SRVER'S SW{TCH INSTALLATION
Calcu/ate Inspection Fee - This Inspection Request will not be
�ther Installations Fee # Service Entrance Size Fee
Mobile Home Park Stall 0 to 200 Amps
Street Ltg. / Traffic Sig. Above 200 Amps
Transformer/Generator INSPECTOR'S USE ONLY
Sign / Outline Ltq. Xfmr.
�ted without the correct fee.
# Circuits / Feeders Fee
0 to 100 Amps
Above 100 Amps
TOTAL
��
- -- I hereby certi that I inspected the electrical installation described herein on the dates stated:
11'1'IgBtlOf1 BOOm Rough In Date
X Special Inspection 1i� c�0- S�
Investigative Fee Fina� oay�� �
/
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requ�t void 18 maHhs from validation date printed in this box. �
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*085461 �9* 7�(D
Request Date Rough-In inspection required? ❑ Yes ❑ Inspection Other Than Rougliyc ❑ Ready Now � Will Call
np�,�,�� You must call the inspecror when ready� Date Ready: n __ _ ___
I, []Qicensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Jo�Qcj{iLg� (Street, �,,Qr�oyt� _ � � City ��Y Z�p Code:
1f��L1 C'� t�F�EK ��
Section No. Township Name or No. Range No. Fire No. County �A
� � A Phone No. ���.j�.���a
.iQ
Pp�,¢�pplier Addr@�� S ��'�
�x' IYR�•L
lectri al C ntractor / Com n Name Contractor License No. Master Lic. No. (Plant Elect. Only)
��..� �c�c co.. itt��cc. cao�iez
Mailing Address (Contractar, Company or Owner Perfortning lnstallation) �'2 1-d712 I 8�2 .��i
12467 BOOt� AVE S. Sr4VAGE. A�NV. 53378 i � ( �-
Authorized Signature (Contractor, Com erforming In tip_n) Phone Number
_ � ��'".e.,� i )
EB-00001A-12 5/1999 STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY