P - 83750REQUEST FOR ELECTRICAL INSPECTION
4.�v' �- 9 5 5 Minnesota State Board of Electricity
, 1821 University Ave., Rm. S-128, St. Paul, MN 55104 �;
� ,Phone (612) 642-0800 ���
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re air
ir Con . Htg. E uip. Water Htr. Load Mgmt. Other:
� ryer �� ang � Elec. Heat Temp. Service
'X" above the work covere this request. Enter remarks in this space and on the back of the white copy only. i
Calculate Inspection Fee - This Inspection Request will not be acc<
Other Fee # Service Entrance Size
Mobile Home Park Stall 00 Amp
Street Ltg./Traffic Sig. Above 200 Am
Transformer/Generator INSPECTOR'S USE ONLY
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
withoUt ihe correct fee:
Fee # Circuits/Feeders
0 to 100 Amps
Above 100 Ar
Fee
I!�ereb certi fhat I ins ted fhe eleckical installation described herein on the dates stafed
Irrigation Boom Rough-In p
Special lnspec — t�
Finol J pa�
Investigative Fee � Z
THIS INSTALLATION MAY BE ORDERED DISCO ECTED IF NOT COMPLETED ITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 months From validafion dafe prinfed in,thi� x.
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I IIII II ��I II III I) II) II �I II II) II III � 5�
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* 0 4 9 8 9 5 5 4 iK PLEASE PRINT OR TYPE
Request Date Rou h-in ins ection r uired? Yes
g p eq ❑ No Inspection Other Than Rough-in: ❑ Ready Now ❑ Will Call
$,_(.�,_�'7 �You must call the inspecfor when ready� Date Ready:
I, icensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Street, Box, or Route No.) City • Zip Code
I 5 a C � sa� �. ►2 ��.�
Section No. Township Name or No. Range No. Fire No. County ,
��'e.nn � v�
Occu ar phone No.
Power Supplier
1 � J�
Elecfrical Conhacfor (Company Name)
CITIES �LECTRIC, WC.
Mailing A r`a r�P ,�nsb
� D w463'�310
W
Conhacfor License No. � Master Lic. No. (Planf Elect Only�
No.