P - 83307� RE(�UEST FOR ELECTRICAL INSPECTION •
6���� O/� � Minnesota State Board of Electricity 3
, �� 1821 University Ave., Rm. S-128, St. Paul, MN 55104 �.
Phone (612) 642-0800 `' '
Home Duplex Apt. Bidg. Other: New Addn
Commercial Industrial Farm Remod Re air
Air Co Htg. E' Water Htr. Load Mgmt. Other:
Dry ng Elec. Heat Temp. Service
"X" above the work covere by this request. Enter remarks in this space and on ihe back of the white copy only.
Calculate Inspection Fee - This Inspection Request will not be accepied without fhe correct fee:
Other Fee # Servi Entrance Siz Fee # Circuits/Feeders fee
Mobile Home Park Stall 0 Amp 0 to 100 Amps
Street Ltg./Traffic Sig. Abo 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTA �� \
Sign/Outline Ltg. Xfmr. �J
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ted the el ' al insMllation described herein on the dates slated
Irrigation Boom RougMn D �
Special Inspecti
Final
Investigative Fe
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 monihs from v a dafe printed in fhis box.
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I I� I� III �I I�� I� I�I II (��I III II �I ��II 1�I
* 0 6 7 8 7 0 4 8* ���
PLEASE PRINT OR TYPE
Requesf Dafe Rough-in inspecfion required� es ❑ No Inspection Olher Than Ro�gMn: ❑ Ready Now ill Call
b� .� �You must call the inspedor when ready) Daffi Ready:
I, icensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Shee1, B x, or Route No. � Ciy y� Zip Code
-P�QP/y= � j -�
Secfion No. Township Name or No. Range No. Fire No. Cou
Phone No.
Pow�upplier Address
�
Electrical Conhactor �Company Name� Conhactor License
CITIES ELECTRIC, INC. Ck�Q 3S1
Mailing Address �Conhactor or Owner Perfwming Insfa lafi��„ _3810
d. t � ,
Owne��n) A 6 5�� I Phone No.
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY