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P - 816111-416-748 �4 REQUEST FOR ELECTRICAL INSPECTION �` E Minnesota State Board of Electricity - '� 1821 Universiry Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 =— (651) 642-0800 www.e/ectricity.state.mn.us :- `" Home Dupiex 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 on/y. (v�i� S�3l�i•�'� S'Y`�'i`i`ti:F-i i€VSit'�L..Lr`,i"i�1�V Ca/cu/ate Inspectic Other InstaNations Mobile Home Park Stall Street Ltg./ Traffic Sig. Transformer/Generator Sign / Outline Ltg. Xfmr. Alarm/Remote Conirol Swimming Pool Irrigation Boom Special Inspection Investigative Fee Fee - This Inspection Request will not be accepted without the correct fee. �e # Service Entrance Size Fee # Circuits / Feeders Fee 0 to 200 Amps 0 to 100 Amps Above 200 Amps Above 100 Amps INSPECTOR'S USE ONLY TOTAL �0.'�iI I hereby certify that I inspected the electrical installation described herein on the dates statec Rough In Date ON MAY BE ORDERED �ECTED IF NOT .....��_�:.�.,.,.�.,�.: ••�...........�,.._.......,_.�.�.. IIIIII �IIII IIIII III� IIII) II I I�III IIII IIII OPFlCE 1►SE ONLY This requeat vad 18 � �a�l Z^2 z ,� LETED WITHIN 18 MONTHS. ......,� ...............................,,:,,,�,;,......,.�, om validation date printed in this box. * 1 0 1 6 7 � 4* �� \`�` � '�t�MBF� a�?C?[1B�lt?C� � " PLEASE PRINT OR TYPE Request Date Rough-In inspection required? ❑ Yes ❑ d Inspection Other Than Rough'I�l: � Ready Now ❑�II Call �������-��� You must call the inspector when readyl Date Ready: ��i%��Q I, �I�censed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at: Job Address (Street, Box, o� Route No.) City Zip Code: o���o s� rrr � n�r �� Q�c FRI i�LEY ��►�� Section No. Township Name or No. Range No. Fire No. County ��� Occu ant Phone Na. C)�i..Z�.��. . A�.l_Ei�l � (7�3)5?1-0853 Power Supplier Address NSP MPLS OFFI GE Electrical Contrador / Company Name Contractor License No. Master Lic. No. (Plant Elect. Only) MASTER CLE�TRIC C(:�., fNC. CA011S2 Mailing Address (Contractor, Company or Owner Performing Installation) � 12 (]QNE AVE S: SAVAGF. MN. 5�;:�78 (783�93-00381(952jSS0-3�55 oriz i ature (Contractor, Company or Owner Perfwming Installation) Phone Number \ � EB-00001A-12 5/1999 STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY