P - 83966I 49�=9�9 6
Commercial � � Industrial
Air Cond�� Ht�
REQUEST FOR ELECTRICAL INSPECTION - �
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
this request. Enter remarks in this space and on the back of the white copy only.
� Calculate Inspection Fee - This Inspection Request will noi be accepted wifhout the correct fee:
Other Fee # erv' e Entrance S'- Fee # Circuits/Feeders Fee
Mobile Home Park Stall 00 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Ab e 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE 6NLY TOTAL !�
Sign/Outline Ltg. Xfmr. � �
Alarm/Remote Control '�
Swimming Pool � �j � �-�"� ' li
I hereb certi fhat I ins ected the e� I installafion deuribed e�ein n the d s sta
Irrigafion Boo RougMn ' Dare
Special lnspe � �� � � ��
Pinal Da �
Investigative Fee p� — �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 ONTHS.
OFFICE USE ONLY This requesf void 18 months from validafion dafe prinfed in fhis box.
� ��� �
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* � 4 9 8 9 6 9 5� PLEASE PRINT OR TYPE �5��
Requesf Date— � Rou h-in ins fion r uired? es
g pec eq ❑ No Inspecfion Other Than Rough-In: Ready Now ill Call
�You must call the inspector when ready) Date Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sireet, Box, or Route No.) � City � Zip Code
13 a C� sr-� ��a �' .��.c �o �� �
Section No. Township Name or No. Range No. Fire No. County �, �
fl �' Ll.fiy! b
' Power �lie� �
� Electrical Contracror (Company Name
CITIES FLECT�IC, INC.
^ G-22�Tii 3T. W., rG�
Mailing Address (Contracror or Owner PerFormi
� _ ii w ,
Phone No.
CA00381 I Contractor License No. I Master Lic. No.
h1N 55024