P - 84422/.'
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4�r. � REQUEST FOR ELECTRICAL INSPECTION
L� ��� 2 Minnesota State Board of Electricity ��'
r 1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
ome Duplex Apt. Bldg. Other: •
Commercial Indushial Form Ne�'✓ Addn
Air Cond. Htg. Equip. Wate� FIfr. Load M mt. Remod Re air
9 Other:
�X" above the work co�ve � by this requestHEnter remarks in this space and on ihe back of the white co
�Q �y1 � � -1 J PY only.
Calcu/aie Inspection Fee - This Insp�
Other Fee
Mobile Home Park Stall
Street Ltg./Traffic Sig.
Transformer/Generator
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Ppol
_ Irrigation Boom
�n Request will not be accepted without the correct fee:
# Service Entrance Size Fee #. Circuits/Feeders
0 to 200 Amps F�
0 to 100 Amps
Above 200 Amps Above 100
INSPECTOR'S USE ONLY Amps
TOTA
.. � ,'� �,
rhar I
on the dates
Date
THIS INSTALLATION MAY BE ORDERED DISCONNECTED F NOT C-� p~jy�p Ep yy�THIN 18 MO HS
OFFICE USE ONLY This requesf void 18 months from validation dafe prinfed in fhis box.
IIIII II III II III II I � � /� �� �\
II I I, I' If III
II III II �II I� ��� I !— .
* 0 4 2 2 2 3 2 9* �5$3�
keqoesr oote
PLEASE PRINT OR TYpE
EM Roogh-in inspec}ion required? ❑ Yes No Inspection Other Than Roughan: Read Now
� �(�, � �Y musf call fhe inspecfor when ready) Date Ready: Y ❑ W�II Call
l, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
1ob Address (Sfree�, Bo or Roufe No.
���� � � Ciy �` Zip Code
C!�'UCl Y' (Ql� �^ v
Secfion No. Township Name or No.
Range No. Fire N� r�__` —
Phone
Power
ectrical Conhactor (Company Name) .
Conhactor License No.
Harrison Electric, Inc. CA00808
����^9 A u(Conhador or Owner Performing Installafion)
5 5 Nevada 301 olden Valle
thor' S' ture ucfor r ner • ng Insfallafi � M
2�8��� F
i000 -
STA A D COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY
i (, �
ter Lic.— No. �p�a�� �
�
, 55427
e No.
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