P - 80773REQUEST FOR ELECTRICAL INSPECTION �
V-854-591 � Minnesota State Board of Electricity _
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993
y (651) 642-0800 www.electricity.state.mn.us
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Repair
Air Conditioner Htg. Equip. Water Htr. X 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.
n� ss��„vEas svwTCH in�sr�a.u►►-nav
Ca/cu/ate Inspecti�
Dther Installations
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
Transformer/Generator
Sign / Outiine Ltg. Xfmr.
Alarm/Remote Control
Fee - This
;e #
not be accepted without the correct fee.
0 to 200 Amps 0 to 100 Ai
Above 200 Amps Above 100
INSPECTOR'S USE ONLY
TOTAL
' I hereb certiTy that I inspected the electrical installation described herein on the dates stated:
Irrigation Boom Rough In Date
x Special Inspection 15.�
Investigative Fee Final � � oa `z ��� !
/
THIS INSTALLATION MAY BE ORDERED DISCONNE D IF NOT COMPLETED WITHIN 18 MONTHS.
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OFFICE USE ONLY Thia request void 18 months from validation date printed in this box.
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Request Date Rough-In inspection required? � Yes ❑�Q Inspection Oiher 7han Rougf�-jn: O Ready Now � Will Call
� j�,�� You must call the inspector when ready!ti Date Ready: �� ___ ___ _
I, [j�icensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Jo�c��g� (Street, B�c, o+r�Ra e No. �� City ��EY Zip CodC�.32
11A7 KI :r,�y
Section Na. Township Name or No. Range No. Fire No. County �A
� � G Phone No. �Q�����_��
V
Pqr(�.�PPlier Addrgss�,,,�, S ��'�
�w�r• R/���.
Electrical Contractor / Compan Name Contractor License No. Master Lic. No. (Plant Ele�
awsrER �cr�e co.. �nic. caa1 �e�
Mailing Address (Contractor, Company or Owner Performing Installation)
42d67 BL�01� AVE S. SAVA�,.�iINV, 55378 j (�12�41-07121 (612�1
Authorized Signature (Contractor, Comp� r Performing Installation�! (,� :1 _ Phone Number
EB-00001A-12 5/1999 ��ATE BOARD COPY SEE 1NSTRUCTIONS ON BACK OF YELLOW COPY