P - 81612q REQUEST FOR ELECTRICAL INSPECTION �"°"
�'0 ��-��" � Minnesota State Board of Electricity ti:- .,
,� - 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 Atldn
Commercial Industrial Farm Remod Repair
Air Conditioner Htg. Equip. Water Htr. st 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.
�V;=ifa :a,u.VE�'S 5'�J`i'�f �,.;'1��9 iiri.`�!'.�I_.fhTl}�f�l
Fee - This Insnection Reauest will not be accevted without the correct fee.
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg. / Traffic Sig. Above 200 Amps Above 100 Am�
TransformedGenerator INSPECTOR'S USE ONLY TOTAL
Sign / Outline Ltg. Xfmr.
� I hereby certity that I inspected the e�ectrical installation described herein on the
6o�irl � Rouah In ate
Investigative Fee - ---
THIS INSTALLATION AAAY BE OR ED DISCONNECTED
............................................,..,........................................... .. . _ _ . ..
� I���I� �II IIII) �I III�I II� �III l� . OFFICE USE ONLY �This raquest void 18 months from validatian date printed in this box.
� \
* � 0 1 _6 2 * ��,�11'`a �� . �r,�?�E��� �?o�i3C�nn
�
PLEASE PRINT OR TYPE
Request Date Rough-In inspection required? � Yes ❑ Inspection Other Than RoughAA: 0 Ready Now � Will Call
��+ ����� Vou must call the inspector when ready! Date Ready: (]�''j(�(}f(a(�
I, [�licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address (Street, Box, or Route No.) City Tp Code:
C11�a�34 TRGLL.Ht'�..�"`7EN C�� FFtIC3LEY �542`l
Section No. Township Name or No. Ranqe No. Fire No. County
1�Q%�
Occu ant Phone No.
Si�v1E s� � �.. �RANCiS J (t�12j58B-f1757
(�iSP "'� tvIP�.B OI=FiCE
Electrical Contrador / Company Name Contractor License No. Master Lic. No. (Plant Elect. Onty)
r�r�.�-r�-R ��_��:�r�z�r~ tW t�., ��}r_., CAU7 �92
Mailing Address (Contrac[or, Company or Owner Performing Installation)
��� �o�n�� av� �, s,�v,��E, r�n►, ����a ( r c�3���-�o��i{��2�e�a-����
uth d' nature (Contrador, Company or Owner Performing Installation) Phone Number
\ /
:B-00001A-12 5/19 STA7E BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY