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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. �I��IIIIIIIIIII II IIrI�IIII�I �� 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���— ^��. ���� I 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. � � r '��� � STAT OARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY