P - 84419REQUEST FOR ELECTRICAL INSPECTION
4��- 213 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
Commercial Indushial Farm Remoc
r Cond. Htg. Equip. Water Hfr. Load Mgmt. Other:
Dryer Range Elsc. Heat Temp. Service
"X" above the work covered by this request Enter remarks in this space and on the back of the while copy
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Calculate Inspection Fee - This Inspection Request will noi be accepied withoui the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOq'S USE ONLY TOTAL
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$ign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
Irripation Boom
thot I ins ed the electrical insiallation described herein on the dates smled
Date
� Investigative Fee F� � � f' ] � � . . ._. ( � ���Z �' --�-5
THIS INSTALLATION MAY BE ORDERE4 D�SCONNECTED IF NOT COMPLETEI� WITHIN 18 MONTHS.
OFFlCE USE ONLY This requesf void 18 months (rom validation dafe printed in this box.
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* 0 4 2 2 2 �+ 3 9 A E PRINT OR TYPE�O (J
LE S
Request Rough-in inspection required? ❑ Yes No Inspection Other Than RougMn: Ready Now ❑ Will Call
/�� �/q � (You must call the inspeclor when ready� Date Ready:
I, �censed contractor ❑ owner hereby request inspection of the above elecfrical work at:
Job Address (Skeef, Box, or Route No.) City ^� Z�P
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Section No. Township Name or No. Range No. Fire No. County� �
Occupan�
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Phone No.�^� � ^ � � � �
echiml Confracfor �Company Name� Conhaclor License No. Masfer Lic.
Harrison Electric, Inc. CA00808
wiling Addre nkacfor or Owner Performing Installafion� -
2525 Ne ada Ave. N#301, Golden Valley, MN, 55427
uthorized i natur on t r e 'ng I sfallaKon) �� Phone No.
54�4-3300
���A"� STAT B RD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY