P - 84718REQUEST FOR ELECTRICAL INSPECTION -
5 0 0� 0 4 3 Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104 -
, ' Phone (612) 642-0800
Home Duplex Apt. Bldg. Other: New Addn
Commercial Indushial Farm Remod Re air
Air Cond. Htg. Equip. Water Hh. Load Mgmt. plher:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by ihis request. Enter remarks in this space and on the back of ihe white copy only.
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Calculote 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 �'
Sfreet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR's use ON�r TOTAL `` j''G�
$ign/Oudine Ltg. Xfmr. �✓ ,
Alarm/Remote Control
Swimming Pool
I hereb cerli that I ins fhe eleclriwl installaKon described herein on Ihe dafes stated
Irrigation Boom Ro�Mn pare
Special lns
Finol
Investigative f � -Z _
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This req�est wid 18 months from validafio� dale prinled in this box.
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� * O S O D O i 3 5 * LEASE PRINT OR TYPE
Requesf Dale Rou h�in ins fion r uired?
g pec eq ❑ Yes No Inspection O�er Than RougMn: Ready Now 0 Will Call
�'� • 9� (You must call the inspector when ready) Date Ready:
I, icensed conhactor ❑ owner hereby request inspection of the above elecfrical work at:
Job Addreu (Sheef, Box, or Route No.) City � Zip Code
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Seclion No. Township Name w No. Ran . Fire No. nty
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Power Supplier Address
Eleclrical Conhaclor �Company Name) Conkador License No. Masler Lic. No. (Plant Elecf. Only)
Harrison Electric, Inc. CA00808
Nlailing Address (Conhaclw w Owner Performing Insfallation�
2525 Nevada. enue North, 301, Golden Va11e_y 55�27
Aulf�w S' nalure on or P rming In ati Phone No.
544-3300
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