P - 82961R�QUEST FOR ELECTRICAL INSPECTION -
5��-�(� �� P Minnesota State Board of Electricity
J 1821 University Ave., Rm. S-128, St. Paul, MI3 55104
Phone (612) 642-0800
r Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re air
Air Cond. tg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
„X" above the work covered by ihis request. Enier remarks in this space and on the back of the white copy only.
) ����
Calculate Inspection Fee - This Inspection
Other Fee #
Mobile Home Park Stall
Street Ltq./Traffic Sip.
��
Sign/Outline Ltg. Xfmr.
Alarm/Remote Conhol
Swimming Pool
Irriaation Boom
eques► will not be accepted without ihe correct fee:
Service Entrance Size Fee # Circuits/Feeders Fee
0 to 200 Amps 0 to 100 Amps
Above 200 Amps Above 100 Amps
?ECTOR'S USE ONLY TOj�
the elechical installation described herein on the dales
� Imestigative Fd� v� V _ �— l `
THIS INSTALLATION MAY BE ORDERED DISC TED IF NOT COMPLETED WITHIN 18 MONTHS.
OFl-lCE USE ON�Y This request void 18�s hom validation date prinTed in this box.
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* � 5? 1 9 7 4 5* PLEASE PRINT OR TYPE
auest a� � n� Ro h-in ins on uired$
�� j ug pecli req ❑ Yes No Inspec6on O�er Than RougMn: eady Now ❑ Will Call
G �`/ou musf call the inspecfor when ready) Date Ready:
licensed contractor ❑ owner hereby request inspection oF the above electrical work at:
���� dr u Street x, or Rou1e No.) Ciy Zip Code
-�ennett� ��i u� �,td I� ,
Name or No. � Ransae No. � Fire No.
uccup�C.J' ` Ph✓�' � �� I I
� Power Supplier Address
flechical Conkactor (Company Name) Contracfor License No. � Master Lic. No. (Plont Elei
Harrison Electric, Inc. CA00808
. Mailing Address (Conhactor w Owner PerForming Installation)
2525 Nevada Avenue North, 301, Golden Vallev 55427
'�� c� c�►c c� I 544-3300
STATE BOARD COPY - SEE IN ACK OF YELLOW COPY