P - 82674REQUEST FOR ELECTRICAL INSPECTION
�j �="j w�� O Minnesota State Board of Electricity
�� G 1821 University Ave., Rm. S-128, St. Paul, MN 55104 �.
Phone(612)642-0800
Home Duplex Apt. Bldg. Other: New Addn
mmerc' I Industrial Farm Remo Re air
Air n� tg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. 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.
N- G G �r��.I�
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance 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 T�� � O
Sign/Outline Ltg. Xfmr. '
Alarm/Remote Control
Swimming Pool
I he�eb ceAi ihaf I ins cfed the electrical insfallafion described herein on the dates stated
Irrigation Boom RougMn �O}e
Special Inspectio
Final ._z .�
Investigative Fee �:
THIS INSTALLATION MAY BE ORDERED DISCONNECTED �F NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This request void 18 months From validafion dafe prinfed in fhis box.
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II Ili II III II I II III II II
* 0 4 2 2 2 7 0 9* ���
LEASE PRINT OR TYPE
Request Date Rough-in inspecfion required? ❑ Yes Inspecfion Olher Than Rough-In: dy Now � Will Call
12 �3' � Q (You musf call the inspector when ready) Date Ready:
I, �kcensed contractor ❑ owner hereby request inspection of the above electrical work at:
1ob Address (Street, Box, or Route No.) City Zip Code
D f-�- �P � Ff�r�l�
Section o. Township Name or No. Range No. Fire No. County �
Occupanf
Power Suppfier -' � Address
PhoneNo���— ^��.
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Elechical Conhacfor (Company Name� Conhacfor License No. Masfer Lic. No. (Planf
Harrison Electric, Inc. CA00808
Mailing Ad s �Contmctor or Owner Performing Installafion�
2 2 Nevad . N. #301 ;'Golden Valle MN 554
Authori Si tur � n ctor Owner P min Insfallation Phone No.
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'��� � STAT OARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY