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REQUEST FOR ELECTRICAL FNSPECTION --
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
Apt. Bldg. Other: New Addn
Farm Remod Re air
Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
request. Enter remarks in this space and orr the back of the white copy only.
Calculate Inspection Fee - This Inspeciion Request will not be accepted without �he correct fee:
Other Fee # 5ervice E�rance ize Fee # Circuits/Feeders
Mobile Home Park Stall 0 200 Am s 0 to 100 Amps
Sheet Ltg./Traffic Sig. Above 200 Amps Above 100 Ai
Fee
Sign/Outline Ltg. Xfmr. ��` _
Alarm/Remote Control �j�
Swimming Pool
I hereb cerfi that I ins the elechical i Ilation dexribed herein on the dates stated
Irrigation Boom R�+9�� pa Q qQ
Special Inspecti + ��! �: �
F � Fiml Dc•-, .
Irnestigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validafion date printed in this box.
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I il� li III II III � II IN N Iil II III V� I IIII o�-
r
* � 5�a 6 9 7 7 5* PLEASE PRINT OR TYPE
Request DaTe Rough�in inspeclion requiredZ ❑ Yes ❑ No Inspecfion Olher Than RougMn: ❑ Ready Now ❑ Wil! Call
t" S�� � (Vou must call the inspecFOr when ready� Date Ready:
I, icensed contracror ❑ owner hereby request inspection of the above electrical work at:
� Job Address �Skeef x, w RWte No.) Ci � Zip Code
l a'� o '�n� b ��e
Secfion No. Township Name w No. RanBe No. Fire No. Coun . ��
� . . 1�_�. � i . �
il Conkacror (Compony Name)
CITIES ELECTRIC, INC.
�#06•:25Tii ST V►►-. FC1
Address ontracbr or Owner PerFormip�
� . i% w a
Phone No.
CA��� I Conkactor License No.
� - � 259� 3 �.
STA7E BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY