P - 83955r---
RE(IUEST FOR ELECTRICAL INSPECTION _
5� r1' �� �� � Minnesota State Board of Electricity
�� 1821 University Ave., Rm. S-128, St. Paul, MN 55104
�
Phone(612)642-0800
, Home Duplex Apt. Bldg. Other: New Ad
Commercial In trial farm Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Ternp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
���i..� � �'l�-� �
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 Am s Above 100 Amps
Transformer/Generator INSPECrow's usE oN�v TOT� ^
Sign/Outline Ltg. Xfmr. (1�/-�-C-P ?'� �� J��
Alarm/Remote Conhol
Swimming Pool
I hereb certi that I ins the elechical installation deuribed herein on the dates stated
Irrigation Boom RougMn Dafe
Special Insp
Fieal . Dare � .
Investigative Fe �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This request void 18 monfhs from validafion dafe prinfed in this box.
' IIIIIIIIIIIIIIIIIIIIIIIII�IIIIIIIIIII " ��� �
IIIIIIIIII �
, * 0.5 5 0 2 9 9 2 * LEASE PRINT OR TYPE �'�` �
� Requesf i ate Rough-in inspection required? ❑ Yes Inspecfion Other Than RougMn: dy Now ❑ Will Call
(You must call the inspector when ready� Date Ready:
I, icensed conhactor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sheet, Box, or Route No.� � City �� Zip Code
S Ce.�a� (11 �= t--� ���L '
Section No. Township Name or No. Range No. Fire No. County
V �
Occupa Phone No. �
�-- �� -�
Power Supplier Address
Elechical Conhactor �Company Name) Conhactor License No. Masfer Lic. No. (Planf Elecf. Only�
Harr' on Electric Inc. CA00808
Mailing dress ( onhacfor or Owner Performing Insfallafion)
25 5 N vada Av rth, 301 Golden Va.11ey 55427
Autho z Sig re r or i Pe i In Ilafion� Phone No.
� � •� 544-3300
e,.) •
E�� STATE BO RD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY