P - 84492REQUEST FOR ELECTRICAL INSPECTION —
4 �(] �j (� Minnesota State Board of Electricity
� J 1 J 1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
Home Duplex Apt. Bldg. Other: New Addn
Commercial Indushial Farm Remod Re air
Air Cond. Htg. Equip. Water Htr. Lo Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by ihis request. Enter remarks in this space and on the back of the white copy only.
Calculate Inspection Fee - This Inspection Request will not be accepted wifhout the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Sheet Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TO, �L
Sign/Oudine Ltg. Xfmr. \�
Alarm/Remote ConMol
Swimming Pool
I hereb certi that I ins the electrical installation dexribed herein on the dates staled
Irrigation Boom Ro�Mn Da�e
THIS INSTALLATION MAY BE ORDERED DISCONRECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 months from validation dafe prinled in this box.
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* O 4 O O 9 L°J ��C LEASE PRINT OR TYPE
Requesf Dale Rou n ins on r uired? Yes
gh-i pecli eq ❑ No Inspeclion Olher Than RougMn: ❑ Ready Now Will Call
/�-._� (You must call the inspec�or when ready) Dale Ready:
I, icensed confractor ❑ owner hereby request inspection of the above elecfrical work at:
.bb Address (Skcef, Bwc, or lioule No.� Ci n Zip Code
$ �� ' tQ L.�.
Section No. Township Name or No. Range No. Fire No. County �
Phone No.
S
:onhaclor (Company Name) Conhaclor License No. Master Lic. No. (%anf Elecf.
CITIES ELECTRIC, INC. C/10C381
e 1n5 0
/ � � �Q
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n ing Insfallafion� Phone No,
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-11 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY