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REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800
New
Remod
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Air Co . Htg. Equip. Water Htr. Load Mgmt. Other: `
Dryer ange Elec. Heat Temp. Service
above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
C� 1 ��s�
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Ar
Transformer/Ciene�ator INSPECTOR'S USE ONLY TOT,
line Ltg. Xfmr.
mote Control
� Pool
I
Boom �
that I insoecfed ihe electrical installation described herein on the
Fee
' ' Final I Dafe
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validation date printed in fhis box.
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* �� 7 1 8 6 � �a * LEASE PRINT OR TYPE
Request a Rou h-in ins ecfion re uired? ❑ Will Call
q I� �� g p q ❑ Yes No Inspection Other Than Rough-In: Ready Now
I(You must call fhe inspector when ready� Date Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job $ eef Box or Roufe No.) City Zip Code
����e� i n ��'u� ��
Section No. Township Name or No. Range No. Fire No. C unm �
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Power
_trical Conhacfor (Company Name) Conhacfor License No. Master Lic. No. �Plant Elect.
Harrison Electric, Inc. CA00808
iling Address �Conhador or Owner Performing Insfallafion) . .
2525 Nevada Avenue No , 301, Golden Valley 55427
hor.i Signature C nhactor or Ow r Pe Injtall 'on� � j. � A� Phone No.
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54�-3300
OOOIA-11 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY