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Commercial I I Industrial
"X" above the work
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
Farm
Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
requesf. Enier remarks in this space anc
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on the back of the white copy only.
Calculate Inspection Fee - This Inspection Request will not be accepied withouf the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 00 Amp 0 to 100 Amps
Sireet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR•s use oN�r • TBTA�L ����>0�
Sign/Outline ltg. Xfmr. 7� T.J'
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ted fhe elecfrical insfallafion described herein on the dates sMfed
Irrigation Boom Rough-In Da
Special Inspectio + � �T ��� � ^ ��— � �
Final ♦ Da
Imestigative Fee
�THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This requesf void 18 monfhs (rom validafion dafe prinfed in fhis box.
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Ir'�II III I III II III I III�
* � 4 9 8 9 �a L 2* PLEASE PRINT OR TYPE ��'..J�-"
Requesf Date Rou h-in ins fion r uired? Yes
g pec eq ❑ No Inspection Ofher Than Rouglrin: ❑ Ready Now Will Call
1 O—� � q� �You must call fhe inspecfor when ready) Date Ready:
I, icensed contractor ❑ owner hereby request inspection of the above electrical work at:
1ob Address �Sheet, B or Rou�e No.) C' Zip Code
1 a ol �{�K � Sr-e�5 o t� �" ��` � Le.
Secfion No. Township Name or No. Range No. Fire No. County �
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Occ4pypt Phone No.
Power Supplier
l� S �'
Elechical Conkactor (Company Name)
CITIES FLECTRIC, INC.
Mailing A j ctor or ner Pe�
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EB-00001 A-1 1
CA00381
�N 55024
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