P - 81192� REQUEST FOR ELECTRICAL INSPECTION �` E
- 0-854'VOQ � 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 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 only.
NSP SAVER'S 81MTGH INSTALLATIUN
Calculate Inspection Fee - This Inspection Request wil/ not be
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
TransformerlGenerator
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
0 to 200 Amps
Above 200 Amps
INSPECTOR'S USE ONLY
without the correct fee.
Circuits / Feeders
0 to 100 Amps
Above 100 Ampa
TOTAL
Irrigation Bo I hereb certi that I inspected the electrical installation described herein on the dates stated:
Rou h In Date
ii Special Inspection •
Investigative Fee Final Dat l2�_��
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
. . . ..:.............,�.,� ................w_....�.........�...._._......,..�_.....�..-..-•---._..__._«....-•---- •--•-- .�..._..- --
OFFICE USE ONLY This request void 18 monihs from validation date printed in this box.
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75�
*08546087*
Request Date Rough-In inspection requiretl? ❑ Yes ❑ I� Inspecfion Other Than RougFdn: ❑ Ready Now C] �II Call
�1.� You must call the inspector when ready? ` Date Ready: 1�
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I, [jQicensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Jo�s (Street, �,g.Bo���K ,� � City ���Y zP � r�3Z
c�,�
Section No. Township Name or No. Range No. Fire No. CouMy ��
�TV� ��
Phone No. ts�2�%f—��..
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•��p.r..... ......1�"'L.r� 1.Irf'� .
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e rical ont ct r/ o�m7oany^ �rt.''�• ContractoG iA� �� Master Lic. No. (PIaM Elect. Only)
�• 1�\r V I"�W 1
1�2�87 �e� (BOOfVE AVE S. �SAW8At3E, ��lv11V.��55378 � � ( �-�
�, r, e12 1-47t2 ! 812
Authorized Signature (Contractor, Company er orming Installation) Phone Number
\ /
EB-00001A-12 5/1999 BOARD COPY SEE INSTRUCTIONS ON BACK OF YELIOW CAPY