P - 82582�
,�'014-549 80 REQUEST FOR ELECTRICAL WSPECTION �= �`
. Minnesota State Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 �'�.,. �- ��
�.
(651) 642-0800 www.electricity.state.mn.us "�:��.
��� :.:::
'X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
N�P �AVER'� �WITCFi
`��l�k�
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee.
Other Installations Fee # Service Entrance Size Fee # Circuits / Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg. / Traffic Sig. Above 200 Amps Above 100 Amps
TransformedGenerator INSPECTOR'S USE ONLY TOTAL
Sign / Outline Ltg. Xfmr. � �
Alarm/Remote Control
Swimming Pool
I hereby certify that I inspected the electrical installation described herein on the dates stated:
Irrigation Boo�n aou9n in Date
Special Inspection
Investigative Fee Final Date
` �� Q,�
THIS INSTALLATION MAY BE ORDERED DIS NECTED IF NOT COMPLETED WITHI 18 MONTHS.
- � • ---- ..._.._._ ................................._.....�.u.......�,...L...y�..,..
I IIIIII IIII� IIIII IIIII IIIII IIIII ��� v
III IIII IIII OFFICE USE ONLY This request void 18 months from validation date printed in this box.
�V ' ��
� * � o y 4 5 8 * � � � �� �3�
�
Request Date
PLEASE PRINT OR TYPE
Rough-In inspection required? � Yes ❑ NG Inspection Other Than Rough-In: L} Ready Now ❑ Will Call
You must call the inspector when ready! Date Ready:
I, [�icensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address (Street, Box, or Route No.) Ciry Zip Code:
► f♦
Section No. Township Name or No. �43L
Range No. Fire No. County
----- -- ----------__�______ AN4KA
Occupant
Phone No.
MORKRID RtCHARd J
NSP
Mailing Ad
�
Authorized
Name
(Contractor, Company or Owner Pertorming Installa�
TERRITURIAL ROP,Q SAINT
�.ture (Contractor, Company or Owner Performina In:
Contractor License No.
R41d 551 i 4
Master Lic. No. (Plant Elect. Only)
Phone
EB-00001A-12 5/1999 STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY