P - 825801. -� 14-827 �
. ��
REQUEST FOR ELECTRICAL INSPECTION i��=�
�' u:....
Minnesota State Board of Electricity ��� `3
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 ... -:
(651) 642-0800 www.electricity.state.mn.us :��
v Home Duplex Apt. Btdg. Other: New Addn
Commercial Industrial Farm Remod Repair
Air Contlitioner Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elect. Neat Temp. Service
'X" above the work covered by this request. Enter remarks in this space and on the back ot ine wnrte copy onry.
Calculate Inspectic
Jther Installations
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
TransformedGenerator
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
Irrioation Boom
NSP �AVER'� �WITGH
� Fee - This Inspection Request will not be
Fee # Service Entrance Size Fee
0 to 200 Amps
Above 200 Amps
INSPECTOR'S USE ONLY
I hereby certify that I inspected the electrical
Rough In
���4�
without the correct fee.
Circuits / Feeders Fee
0 to 100 Amps
Above 100 Amps
TOTAL
LU. JU
�n described herein on the dates stated:
Final uat
Investigative Fee � ° I � �Z -�?� I
THIS INSTALLATION MAY BE ORDERED DISC NECTED IF NOT COMPLETED WITHIN 18 MONTHS.
. OFFICE USE ONLY This request void 18 months from validation date printed.in.this box.���
IIIIII IIIII IIIII IIIII IIIII I IIIII IIII IIII �•�
* � � � 4 O 7 C? * � V -L -� � � �
�a3
PLEASE PRINT OR TYPE
Request Date Rough-In inspection required? � Yes ❑ N6� Inspection Other Than Rough-In: [� Ready Now � Will Call
You must call the inspector when ready! Date Ready:
I, [j.jicensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address (Street, Box, or Route No.) City Zip Code:
c � i �a�f
Section No. Township Name or No. Range No. Fire No. County
------ --- ------------------------ • AIVQKA
Occupant Phone No.
�VELS�N D�RIS L
Power Supplier Address
NSQ
Electrical Contractor / Company Name Contractor License No. Master Lic. No. (Plant Elect. Only)
++ w e. w n
Mailing Address (Contractor, Company or Owner Performing Installation)
23±V? T�RRIT�RlP.L RnP.D SP.IMT PP,�!L R�N 55114
Authorized Signature (Contracior, Company or Owner Performing Installation) Phone Number
\ 'i0
EB-0OOO1A-12 5/1999 STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY