P - 8141272�-849 �
�...
REQUEST FOR ELECTRICAL INSPECTION ��
Minnesota State Board of Electricity
1821 Universiry Ave., Rm. S-128, St. Paul, MN 55104 ��� !
Phone (612) 642-0800 '�'� �
. Olher New �ddn
� omm I ustriol Form
tg. Equip. Wafer Hfr. Load Mgmt. Ofher.
Range Elec. Heat Temp. Service
"X" o6ovg the �k mvered by �his requesL Entei remorks in ihis spoce ond on fhe back o� fh
U� ���� /
Calcula�e Inspedion Fee - This Inspection Request w�ol be occepfe�'d/� mrrxt fee:
Other Fee # Service Enhance $ize Fee N Circuifs
Mobile Home Pork Stall 0 to 200 Amps 0 fa 100 A
Sireet Ltg.J7raffic Sig. Above 200—Amps A6ove i00
Trnnzfnrmer�Cienemtor INSPECTOR'S USE ONLY
that I inscec�ed Ae
Y7�7
Fee
Investigative Fee `� ��. . _ -'Z — �—�'
THIS INSTALLATION MAY BE ORDERED DISCON ED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesl void l�ihs From wlidation dale p��'t�
1�II II III il Ill II III II III�I II I I II III il III I IIII
* 0 7 2 4 8 4 9 5 s G�a�
P EASE PRINT OR TYPE
Reqve Date RougMn Inspetlion reqoired2 ❑ Yes Inspecrion O�har ihan RougMln: Now 0 Will Call
'� ' IYov musr mll ihe inspecror when rea Dale Reody:
I, icensed conlmctor � owner hereby requesf inspecfion of iFie above elecfrical work ot:
•.a
� m,a�u�9
:nen
Harrison
Rorge
Inc
Fire No.
•��i��
� V / /
1, Golden Valley, M4i 55427
�+U `, Phme No.
�11V I V 544-3300
IN eACK OF YELLOW COPY