P - 80290i ,
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REQUEST FOR ELECTRICAL INSPECTION �" �
� Minnesota State Board of Electricity
1821 University Avenue Suite 5-128, 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 Contlitioner Htg. Equip. Water Htr. v Load Mgmt. Other:
Dryer Range Elect. Heat Temp. Service
'X" above fhe work covered by this request. Enter remarks in this space and on the back of the white copy only.
Calcu/ate
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
Transformer/Generator
Sign / Outline ltg. Xfmr.
Alarm/Remote �ontrol
NSP SAVER'5 SWITCH tNSTALIr0.T10N
Fee - This Inspection Request will not be accepted without the correct fee.
;e # Service Entrance Size Fee # Circuits / Feeders
0 to 200 Amps 0 to 100 Ai
Above 200 Amps Above 100
INSPECTOR'S USE ONLY
Rough In
ciallnspection ap,�
�stigative Fee �
THIS INSTALLATION MAY BE
f Iliflf Ilflf IIIII IIIII IIIII IIIII�fifi�IlN IIII INf
*08530016*
TOTAL
�.i.�J�
Date
' � I �° �-lS'c"�
1ECTED IF NOT COMPLETED WITHIN 18 MONTHS.
Y This request void.78 months from validation date printed in this box.
� I' I , _..�,;�„
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PLEASE PRINT OR TYPE
Request Date Rough-In inspection required?�7 Yes ❑ No Inspection Other Than Rough-In: Ready Now � Will Call
12l27'���� You must call the inspector when ready! Date Ready: � '��7��
I, � licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address (Street, Box, or Route No.) City Z�P �8�
05425 W BRENNER PAS FR{DLEY 55432
Section No. Township Name or No. Range No. Fire No. County
Occupant Phone o.
HOYNE PETER C �g'���78"18�
Power Supplier Address
�P MPLS OFFI GE
Electrical Contractor / Company Name Contractor License No. Master Lic. No. (Plant Elect. Ony)
MAS"TER ELEC'TRI C GQ. , I NC. CA01182
Mailing Address (Contractor, Company or Owner Performing Installation)
92487 BOONE AVE S, SAVAGE. MN, 55378 (B12}941-4712 (612�8L3-355
A Si nature (Contrac[or, Company or Owner Performing Ins � Ptrone Number
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EB-00001A-12 5/19 STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY