P - 80807c=-�'� _ _ _ _ -
REQUEST FOR ELECTRICAL INSPECTION �`` "'
��c.J54_632 � Minnesota State Board of Electricity -
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993
(651) 642-0800 www.electricity.state.mn.us
Home Duplex Apt. Bldg. Other: New Addn
Commercial Intlustrial 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 only.
NSP SAVER'S SIMTGH IIVSTALLATION
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
TransformeNGenerator
Sign / Outline Ltg. Xfmr.
Alarm/Remote Coratrol
Fee - This Inspection Re4uest will not be accepted without the correct fee.
0 to 200 Amps
Above 200 Amps
INSPECTOR'S USE ONLY
0 to 100 Amps
Above 100 Am{
TOTAL
" I hereb certity that I inspected the electrical installation described herein on the dates stated:
Irrigation Boo Rough In Date
i( Special Inspection i �Q
Investigative Fee Final �a �l ��
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COIiAPLETED WITHIN 18 MONTHS.
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OFFlCE USE ONLY Thi��uest voW 18 months from validation date printed in this box.
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Request Date Rough-In inspection required? ❑ Yes ❑ Inspection Other Than RougMn: ❑ Ready Now ❑ Will Call
� Ji7� You must calf the inspector when ready� Date Ready: �� � f+,»
I, [�4icensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
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Section No. Township Name or No. Range No. Fire No. Cc
Zip
, �� f : ►�
I paeu�tr� ��� Q Phone No. tY�i�%��R,4s
IL�Vn 0�7L1
P�pplier Address�� ��C�
E�le�ctAric�al Contractor / C/o�mpany /N+am/+e�wy !�ya Contracto/r+L�ice[n�se No. Master Lic. No. (PIaM Elect. Onty)
�Nr'M71 .�.If ��.ril{t�r �rV.. 11�11�. {..I'�W���
Mailing Address (Contractor, Company or Owner Perfottning Installatlon)
9�dR'7 8v0�E AVE S. SAVA�iE. MN. 56378 I�����-a71Z 1(S12j8�-3556
Authorized SignaWre (Contractor, Co ner Performing Installatio�) Pho�e Numbar
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EB-OOOOtA-12 5/19 STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY