P - 83186RE(�UEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
5 6 6'� 9 8 6 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
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter re arks in this space and on the back of fhe white copy only.
Calculote Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stull 0 to 200 Amps 0 to 100 Amps
Street Lig./TrafFic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator n+svECroR's usE ow�r TOT� � s �
Sign/Oudine Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool 1 her certi tiwf I ins the elechical installation described herein on the dafes stated
Ircigation Boom eo�yMo �°�
$�CIO� �(IS�CtiO Final � - ���
Investigative fee �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFRCE l�E ONLY ihis request void 18 months from validation date printed in this box.
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* � 5 6 6 9 8 6 �a * PLEASE PRINT OR TYPE
R uesT Date R h-in ins on uired? Yes ❑ R Now WiA Call
_� ^� oug pecfi req ❑ No Inspection Olher Than RougMn: eady
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� �You must call the inspector en ready) Date Ready:
I,� licensed conhactor ❑ owner hereby request inspecfion of the above electrical work at:
Job Address (Sheet, 8ox, or Route No.� Ci � . Zip Code
9
Section No. Township Name or No. Range No. Fire No. County .
�pant /\ Phone No.
Power Sup 'er � � ' Address
Eleckical Conhactor (Company Name� CITIES E! ECTRIC, INC. C°"�`���� �ster Lic. No. �Plant Elect. Onfyti
3100-225TM ST. W.. FG ., MN 550Jt
Mailing Address (Conhacfor or Owner Perfo ing Inslallafion)
w • �
Aufhorized Signature (Conhaclor or Own erforming I IlaKonJ 2���g 2 Phone No. �
EB�OOOOIA-11 8/96 y�p� gpppD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY