P - 80804. REGIUEST FOR ELECTRICAL INSPECTION �" ° '
�$54-635 [�0 Minnesota State Board of Electricity
1821 Universiry 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 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 ihe back oi the white copy on►y.
NSP SAVER'S SWITCH 1NSTALLA710N
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
Transformer/Generator
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
Fee - This Inspection Request will nat be accepted without the correct fee.
0 to 200 Amps
Above 200 Amps
INSPECTOR'S USE ONLY
I herebvi certi(v that I
0 to 100 Amps
Above 100 Amps
TOTAL�
installatlon described herein on the dates stated:
x Special Inspection �5•�
Investigative Fee F� / � 1-� r
THIS INSTALLATION MAY BE ORDERED PIECTED IF NOT COMPLETED WITNIN 18 MONTHS,
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OFFICE USE ONLY This request vad 18 months hom validation date printed m this box.
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*08546350* `57g9
PL�I���Q
Request Date Rough-In inspection required? ❑ Yes ❑ Inspection Other Than RougF�yr. ❑ Ready Now ❑ Will Call
�t,�.�p� You must call the inspector when ready� Date Iieady: �� __ __ �„�_
I, [jQicensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Joy,Bd�rp�s (Street, �, �fipytg�o�)„� City ��Y Zp Code:
�Ai� 7 tf hCt,11 tt `i I 1� 5543
Section No. Township Name or No. Range No. Fire No. County �
�►'1=..►:i:�f
e ic I n rac�r / Comp�ny
ELEG'iRl
Authorized Signature
EB-00001A-12 5/1999
ROBEI''YT E Phone No. ��,���7��,�,�Q
Addrgs,�,,,, s ���
MI"L
Contractor License No. Master Lic. No. (Plant Elect. Only)
�.. INC. CAC}1 tq2
or Owner Perfortning Installatlon)
SAVAC�. MN. �5378 (812�41-4712 ! (B12j8�10-3�'i5
or ner i 'on) Phone Number
1 �
STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY