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REGIUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800
Home Duplex Apt. Bldg. Other:
Commercial Industrial Farm
Air Cond. tg. 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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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 / 0 to 100 Amps °i
Sheet Ltg./Traific Sig. Above 200 Amps Above 100 Amps
Transformer/Generator �NSPeCroR'S USE ONLY TOTAL ._..E'',rn
Sign/Outline ltg. Xfmr.
Alarm/Remote Conhol
Swimming Pool
Irriqation Boom
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I hereby cerFify that I inspected the elechical installation described herein on the dates stafed
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Imestigative _ � ;,____`__�- � 2 --
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 months from validafion date prinfed in fhis box.
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Request Date Rou h-in ins fion r uired? pec g dy ❑ Will Call
g pec eq ❑ Yes No Ins tion Ofher Than Rou Mn: Rea Now
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I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Addreu (Sheet, Box, or Route No.) Ci
` �Y . Zip Code
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Section No. Township Name or No. Range No. Fire No. C ny
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Phone No.
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d Conhactor (Company Name� Conhacfor license No.
Harrison Electric, Inc. CA00808
Address (Conhacfor or Owner Performing InstallaTion)
2525 Nevada Ave. N. #301 Golden Valle
:ed Signature (Conkactor or Owner PerForming Installafion� ���;� �
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MN, 55�27
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