P - 83962� j��8-965 mm
Home Duplex
Commercial Industrial
"X" above the work
RE(�UEST 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
request. Enter remarks in �his space and on the back of the white copy only.
Calculate Inspecfion Fee - This Inspection Requesf will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 00 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTA �
Sign/Outline Ltg. Xfmr. ,�
Alarm/Remote Conhol
Swimming Pool
1 hereb certi fhaf I ins ted the el insfallation described herein on the dates sMted
Irrigation Boom Rough-In Dare
Special Inspecti z � �
Firwl ote
Investigative Fee -. � —��
THIS INSTALLATION MAY BE ORDERED DISCO CTED IF NOT COMPI.ETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This request void 18 months from validafion date printed in this box.
� a�L�Q
I IIII II III II III II III II III � II II III II III I IIII � -
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* � 4 9 8 9 6 5 3�K PLEASE PRINT OR TYPE ,�v
Request Date Rou h-in ins eclion r uired2 Yes
g p eq ❑ No Inspection Ofher Than Rough-In: ❑ Ready Now
, l�— �� �You must call the inspecfor when ready) Date Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
lob Address �Sfreef, Box, or Route Clo.� City Zip Code
1�40 �
Secfion No. Township Name or No. Range No. Fire No. Couny ,�
Power
hacror�Company Name�
CITIES FLECTRIC, INC.
Address
CA00381
Phone No.
Call
Master Lic. No. (Plant Elecf. Only)
. ,
C�Mb�ning Insfallafion, -� 6 4 � Phone No.
STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY