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REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800
Apt. Bldg. Other: New Addn
Farm Remod Repair
k' Air C� Htg. 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
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copy only.
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 L 0 to 100 Amps -'
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTALi�.-S'O
Sign/Outline Ltg. Xhnr.
Alarm/Remote Control
Swimming Pool
Irriaation Boom
that I ins the electrical installation described herein on the dates stated
Date
� Investigative Fee � " t " " � . _ ( ' i�' �T b ` ��
THIS INSTALLATION MAY BE ORDERED DISCO ED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This request void 18 months from validation date printed in this box.
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* � 5 2 6 6 6 6 3� LEASE PRINT OR TYPE
Request Date Rough-in inspection required? s No Inspection 01her Than Rough-In: eady Now ❑ Will Call
t� �i �� (You must call the inspector when ready) Date Ready:
I, �licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address �Sheet, Box, or Route No.) City Zip Code
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Section No. Township Name or No. Range No. Fire No. Coun
o«upaor
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Elechical Conhactor �Company Name)
Harrison Electric, Inc.
Mailing Address (Contmctor or Owner Performing inst
25�evada Avenue Dia�t
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Phone No.
,�7/- �l�
Conhacfor License No. Masfer Lic. No.
CA00 08
, 301, lden Valley 55427
stallatio � � � `� � � Phone No.
54�4-3300