P - 80766� REQUEST FOR ELECTRICAL INSPECTION �"' E'
.,.Q_QF/('��Q � Minnesota State Board of Electricity
u�� u 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 Industrial Farm Remod Repair
Air Conditioner Htg. Equip. Water Htr. X 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.
N8P SAVER'S SIMTCH fl�'T'ALLA?lON
Ca/culate Insnection Fee - This Insvection Reauest will not be
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
Transformer/Generator
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
0 Yo 200 Amps
Above 200 Amps
INSPECTOR'S USE ONLY
without the correct fee.
Circuits / Feeders
0 to 100 Amps
Above 100 Amps
TOTAI�
� I hereb certity that I inspected the electrical installation described herein on the dates stated:
Irrigation Boom Rough In Date
Speciallnspection 16.� ��
Investigative Fee F�� C �--"�� �
.
THIS INSTALLATION MAY BE ORDERED DlSCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
........................._._._...._._._._...............,. ,............w W.....W.........,�,.....r.y.� _...... W �..
OFFlCE USE ONLY This request void 18 months from validation date printed in this box.
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*08545980* �4
Request Date Rough-In inspection required? p Yes ❑ Inspection Other Than Roug - ❑ Ready Now � Will Call
� You must call the inspecror when read� Date Ready: �.
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I, [jQicensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Jo�;d r ss (Street, B�x�or�RoV _No.1� � Ciry F�� Ztp Code:
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Section No. Township Name or No. Range No. Fire No. Counry �
� � w �Phone No. �d,Z�I'I�Q,3TI
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P�yy�r,Sypplier Addrgs� S ��l�
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EI rical Contractor / Com an Name Contractor License No. Master Lic. No. (Plant Elect. Only)
� E'I.EC�C' CCi.. ii�. CA041�Z
Mailing Address (Contractw, Company or Owner Performing Installation)
97467 BOQI�E AtIE S. SAVAGE. Mt+i. 55378 (812�41-+l712 !(812�90-33:i�S
Authorized Signature (Contractor, n Aorming Installation) � � Phone Number
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EB-00001A-12 5/1999 STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY