P - 80806� REQUEST FOR ELECTRICAL INSPECTION
�-854-633 0 Minnesota State Board of Electricity
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993
(651) 642-0800 www.e/ectricify.state.mn.us
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial farm Remod Repair
Air Contlitioner 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 hack of the white copy only.
t� s,�►vEas svtinrcH in�sra.�-not�
Ca/cu/ate Inspectic
�ther Installations
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
Transformer/Generator
Sign / Outline Ltg. Xfmr.
AlarmlRemote Control
Fee - This Inspection Request will not be
0 to 200 Amps
Above 200 Amps
INSPECTOR'S USE ONLY
I herebvi certiiv that I
without ihe correct fee.
�ircuits / Feeders
0 to 100 Amps
Above 100 Amps
TOTAL ,
""y'"""" """"' "" Rough In Date
x Special Inspection 15.50
Investigative Fee Final o r_ 2 �
THIS INSTALLATION MAY BE ORDERED DiSCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
.........-- -- - -- �--��- --�--�-- - �-- - - - -��--W._�......• .
OFFlCE USE ONLY Thre request voM 18 months from validation date printed in this box.
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*08546335*
Request Date I Rough-In inspection required? ❑ Yes �� I Inspection Other Than RoughN: O Ready Now � Will Call
�,�� You must call the inspector when rea Date Ready: ��
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I, [jQicensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
JojL�j�,�¢ (Street, Y� lJ��lkt& � F� C�Ty FE�1]4.EY z'P code:
��ocwm a..,��� 5fi432
Section No. Township Name or No. Range No. Flre No. County �
��CH DAVID B
atASTER ELE�'iRiC ��.. iNC.
Mailing Address (Contractor, Company or Owner Performing Ir
12467 B40NE AVE S. SA�. MN.
Authorized Signature (Contractor, pany ner Performi
�81��79-�121
OF�1 GE
Contrector License No. Master Lic. No. (Plant Elect. Only)
CAt�� 1�2
y � �, �, (812�41-Q71Z ! (692j890-35�i
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EB-00001A-12 5/1999 STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY