P - 82675:
f422-261
Home Duplex
Commercial Industrial
Air Cond. Htg. Equi
Dryer Range
"X" above ►he work covered 6
RE�UEST FOR ELECTRICAL INSPECTION �-
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �
Phone (612) 642-0800 "�°'
Apt. Bldg. Other. New Addn
Farm Remod Re air
Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
request. Enter remarks in ihis space and on the back of fhe while copy only.
�g'�l � J 30.°,�me►1.'l"' �c�i-hY�cb►'h. : �' 7C%t.a, U.S� �—�l.i
Calculaie Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entra�ce Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Outline Ltg. Xfmr. L S^J^U
Alarm/Remote Control
Swimming Pool
I hereb certi fhat I ins fed fhe elecfrical installafion described herein on }he dafes sfofed
Irripation Boom Rrn��h-I� Date
THIS INSTALLATION MAY BE ORQERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLV This requesf void 18 monfhs From validation date printed in this box.
Illlllllilllllllllllllllllllllllllllllllllllllll �� �
� 0 4 2 � � Y�����
2 2 6 1 8 PLEASE PRINT OR TYPE
Requesf Date Rou h-in ins ion r uired?
���g pecY eq ❑ Yes No Inspection Other Than Rough-In: Ready Now ❑ Will Call
`� � �You must call the inspecror when ready� Date P.eady:
I, �icensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sheet, Box, or Route No.� City Zip Code
�sa6 �l� S�reef /1//=.' �fz�l�
Secfion No. Township Name or No. Range No. Fire No. Couny
/�rt�al��
Occupa Phone No.
�'2'0�,; 78�1-6s3��
Power Supplier Address -
Elecfrical Conhacfor (Company Name) Conhactor License
Harrison Electric, Inc CA00
Mailing Address (Conhactor or Owner Performing Installation�
�
BOARD COPY - SEE INSTRUC770NS ON BACK OF YELLOW COPY