P - 81191>
REQUEST FOR ELECTRICAL INSPECTION
� 0-854-625 1[] Minnesota State Board of Electricity
1821 University Avenue Suite S-12S, Saint Paul, Minnesota 55104-2993
(651) 642-0800 www.electricity.state.mn.us
Home Dupiex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Repair
Air Conditioner 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 on/y.
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Calculate Inspection Fee - This Inspection Request wil/ not be accepted without the correct fee.
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
TransformedGenerator
Siqn / Outline Lta. Xfmr.
0 to 200 Amps 0 to 100 Ai
Above 200 Amps Above 100
INSPECTOR'S USE ONLY
TOTAL ,�
av. �
Irrigation Boom - � nereby certiiy tnat I inspected tne electrical installation described nerein on me dates stated:
Rough In Date
x Special Inspection 1ii�
Investigative Fee �, o t? w l�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED ITHIN 18 MONTHS.
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OFFICE USE ONLY This request vaid 18 months from validation date priMed in this box.
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Request Date Rough-In inspection required? ❑ Yes ❑ Inspection Other Than Rough�ln: ❑ Ready Now ❑ Will Call
You must call the inspector when ready� Date Ready: ��
I, [jQicensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Jo$��i�0 �Sheet. F�{rt��+RCG►� RD iNE °ity FRIQLEY �P 554$Z
Section No. Township Name or No. Range No. Fire No. Counry ��a
�tlDTZ MARVIN J
Phone No. �61Z ,�79-5Z45
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Electrical Contractor / Com n ame Contractor License No. Master Lic. No. (PIaM Elect. Only)
MA.��'iER ELEG"�i�G� C�.. iNC. CA011�t
1�2467 feSg cBt�AtVE AVE S. �SAVAGE ��t+�NV.Sta�5�v37B (8'l2j949-0T12 !(B'l2j894-3555
Authorized Signature (Contra , ompa Owner Performing Ins t r •,. Phone Number
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EB-00001A-12 5/199 STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY