P - 82733REQUEST FOR ELECTRICAL INSPECTION -
�Z'� �, Q�` Q Minnesota State Board of Electricity
1 .J lJ V 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 air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
D er Range Elec. Heat Temp. Service (� � � ����
"X" above the work covered by this request. Enter remarks in this space and on the back of the whiie copy only.
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Calculate Inspection Fee - This Inspection Request will nof be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuifs/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Sfreet Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOT,��^(f
Sign/Outline Ltg. Xfmr. ��j'�
Alarm/Remote Conhoi '
Swimming Pool 1 hereb ceAi lhot I in ed the elecfrical insfallafion described herein on the dates smted
Irrigation Boom Ra,yMn Dare
Special Ins ti n
Investigafive F� �— Z�
°-- •-�^_�■ ■.�nn�u uev RE�RDERED DISCONNECTED tF NOT COMPLETED WITHIN 18 MONTHS.
�FFICE USE ONLY 7his request void 18 monlhs 6om validafion dafe printed in this box.
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Rey�e P EASE PRINT OR TYPE
��j' ���} . Rough-in inspeclion required2 ❑ Yes o Inspection Olher Thdn Roughan: Req Now
�� � r Q (You musf call the inspecfor when reody) pa� R�d : '.. dY ❑ Will Call
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�,�icensed contractor ❑ owner hereby request inspection of the above electrical',work at:
1ob ress (Sheet, Box, or Roule No,) �
l�Dl -r► n�sbrc�K ,Dr��,o�, �����d ( ' Z,P ��
Seclion No. Townsh(p Name or No. ���.
Range No. Fire No. o �h, �,.
Occupant � � kci.
� �'y �,�J r�., � � Phone No. ....�
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Power Supplier
Addreu
Elechicnl Conhacror rCanpany Name�
Conhactor License No. Muster Lic. No. (plant Elecf. Only)
Harrison Electric, Inc. CA0080g
Mailing Address (Contracror or Owner PerForming Installafion) ..
2525 Nevada Avenue orth 301
AWhorized Signature �Conhacfw er PerForrtri G� �- de ����. L�
�g Ilalion) Phone No.
E�OOOpIq-11 8 96�� �5�� 2�9��
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