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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
Farm New
P• Water Htr. Load Mgmt. Other: Remo�
Elec. Heat Temp. Service
✓ this request. Enter remarks in this space and on the back of ihe white copy
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nspection Request will not be occepted without the correct fee:
Fee # Service Entrance Size Fee # Circuits/Feeders
0 to 200 Amps 0 to 100 Amps
Above 2pp Amps Above 100
INSPECTOR'S USE ONLY Amp:
TOTAL
ihat I ins � �e
Fee
Sp
¢
-----• °•��������.,�� aescnced herein on ihe dafes sfafed
Special Inspec ',. oug -In
Date
Investigative Fee F'"°I
,/�`--� , _� ,
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COAi1PLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This req�est void 18 months kom voiidafion dafe printed in this box.
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* 0 4 6 8 1 5 3 2* ��
Request Date LEASE PRINT OR TYPE
��/ �' �� Rough-in inspection required2 ❑ Yes
7� (You must call fhe ins NO Inspection Other Than RovgMn: Ready Now 0 yy�ll Call
pecfor when readyJ Date Ready:
�, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Skeef, Box, or Roure No.) '
y � �— Ciy � Zip Code
� ✓_/,-' /-�l/�f'v�? /2i.JL ��
Secfion No. Township Name or No. Range No. Fire No. r„�,
Occupant
� ���'�"J�f::�r�►
Harrison Electric, Inc.
9 A��Contracfor or Owner Perfi�„�t�., i.,�...u_.:__�
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r
Phone No.
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Master Lic. No. (Planf
'" 544-3300
COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY