P - 84623REQUEST FOR ELECTRICAL INSPECTION --
4��-191 Minnesota State Board of Electricity
r 1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800
Home Duplex Apt. Bldg. Other: New Addn
Commercial Indusfrial Farm Remod Re ir
Air Cond. Htg. Equip. Water Hfr. load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X° above the work covered by this request. Enier remarks in this space and on the back of the whiie copy only.
S�/r?c�,2 ,�. v..�-r �c�i�T/lc: G'�rLD # �L�D �/ �!
Calculate Inspection Fee - This Inspection Request will noi be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps —
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL/� 3
Sign/Oudine Ltg. Xfmr.
Alarm/Remote Confrol
Swimming Pool I here certi thaf I ins ed the elechical installafion described herein on the dates stated
Irriaation Boo�. .k u,.,�..�., Date
-�---- Firwl �--- ' ,
Investigative Fee /f _ _ G 7 � /
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPIETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 months from validation dafe prinfed in fhis box.
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* � 4 6 8 1 9� 2* LEASE PRINT OR TYPE
Request Date Rough-in inspaclion required� ❑ Yes No Inspection Other Than RagMn: Ready Now ❑ Will Call
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�, .3 � S' % (You musf call the inspeclor when ready� Dafe Ready:
I, licensed contractor ❑ owner hereby request inspection of the above elechical work at:
Job Address (Sheef, Box, or Roule No.� City Zip Code
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Section No. Township Name or No. Range No. Fire No. C nty _
IOccupant
[.� �K'
Address
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Phone No.
,; ?5�-,,2/ 7f
il Conkacfor (Company Name� Conhacfor License No.
Harrison Electric, Inc. CA00808
Address (Conhacfor w Owner Performing Installalion�
2 Nevada Av . N. #301, Golden Valle
'gn Nre (Co; acfor ing Inslallaii
' S176
�� � 8�96 pTE BOpRD COPY - SEE INSTROC71[f1�LS nN RACK []F YFI 1 f)W f
Master Lic. No. (Plant Elecf. Only)
MN. 55427
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