P - 83954REQUEST FOR ELECTRICAL INSPECTION
5 5.� ��i�5 5� Minnesota State Board of Electriciry
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remo Re air
Air Cond. tg. Equip. Water Htr. Load Mgmt. Other:
Ran e Elec. Heat Tem . Service
Dryer g p
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
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Calculate Inspection Fee - This Insp�
Other Fee
Mobile Home Park Stall
Street Ltg./Traffic Sig.
Tra nsformer/Generator
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
Irriaation Boom
rn Request will not be accepted without the correc! fee:
# Service Entrance Size Fee # Circuits/Feeders Fee
0 to 200 Amps 0 to 100 Amps
Above 200 Amps Above 100 Amps
INSPECTOR'S USE ONLY TOTAlJ�,
� �7. _
that I ins ected fhe elechical insfallation described herein on the dafes stafed
Dafe
-r--._. ...-r---- � Final �
Investigative Fee ��--� ` �— �^ L� ��
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 months from validafion dafe prinfed in fhis box.
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* � 5 5 � 1 5 5 6�Ic PLEASE PRINT OR TYPE ����
Request Dafe Rough-in inspecfion required? ❑ Yes No Inspection Other Than Roughan: Recdy Now ❑ Will Call
� � (You must call the inspector when ready) �� Date Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address �Sfreef, Box, ute No.) City Zip Code
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Section No. Township Name or No. Ranpe No. Fire No. Co ny ;/�
Power
Address
Phone No.
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Elecirical Confractor (Company Namej Conhactor License No. MasMr Lic. No. �Plant Eiect. Only�
Harrison Electric, Inc. CA00808
Mailing Ad s(Confractor or Owner Performing Insfallation) � �
25 eva.da Avenue North, 301 Galden Valley 55427
Aufhor' Sig re,{� f��ctor or ner P rfor i g Insf lation) Phone No.
, %/ti'/��v// � �- � �/�� ��2 54�4-3300