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
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LETED WITHIN 18 MONTHS.
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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
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EB-00001A-12 5/1999 STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY