P - 80777.
. � �0-854-587 []
E
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity -
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993 -_ -
(651) 642-0800 www.electricity.state.mn.us
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industriai Farm Remod Repair
Air Conditioner Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elect. Heat Temp. Service
'X" above the work covered 6y this request. Enter remarks in this space and on the back of the white copy orny.
NSP SAVER'S SIMTCH INSTALLAl1UN
Calcu/ate Inspection Fee - This Inspection Request will
Mobile Home Park Stall
Street Ltg. 1 Traffic Sig.
Transformer/Generator
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
0 to 200 Amps
Above 200 Amps
INSPECTOR'S USE ONLY
without the correct fee.
�ircuits / Feeders Fee
0 to 100 Amps
Above 100 Amps
TOTAL �
I hereb certi that 1 inspected the elechical i�stallation describad herein on tha dates stated:
II'�IgBtlOfI�BOOf11 Rough In Date
Special Inspection
Investigative Fee F�"� o . — � '
THiS INSTALLATION MAY BE ORDERED DISCONNECTED fF NOT COMPLETED WITHIN 18 MONTHS.
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OFFICE USE ONLY This request void 18 months from validation date printed in This box.
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08545873
Request Date Rough-In inspection required? � Yes ❑ No Inspection Other Than Raugh-In: ❑ Ready Now ❑ wll Call
You must call the inspector when ready%� Date Ready: X
�c�na�u� . .. . -- — — --
I, [�licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Joh Address (Street, Box, or Rouie No.) City Zip Code:
QT11k5 RiVERViEW TER tVE FRICk.EY 5�'i432
Sedion No. Township Name or No. Range No. Fire No. County AaVyt A
rY�J�V•\
Y
Phone
PEPITO C
Address �y
�S V�"r1 .�
Contractor License No.
(81Zj514=1�� ,
MASTER E1.EG"ii�C CO., INC. CA011�
Mailing Address (Contractor, Company or Owner Performing Installation)
9�067 BUOI�E AVE S. SA , MN. 55378 (812jQ41-4712 /(812�6F3-3�
Authorized Signature (Contractor or Owner Pgrtorming Installatlon) Phone Number
c � 1
EB-00001A•12 5/1999 STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPV