P - 83308REQUEST FOR ELECTRICAL INSPECTION T
6���Z 0� � 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 ndustrial Farm Remod Re air
i� Co tg. Equip. Water Htr. Load Mgmt. Other.
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
Calculate Inspection Fee - This Inspeciion Requesi will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 00 Amp f 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL `� \
Sign/Outline Ltg. Xfmr. ✓ Q
Alarm/Remote Control
Swimming Pool
. I hereb certi thaf I ins ted fhe elecfrica) installation described herein on the dafes stated
Irrigation Boom RougMn �r� y, �
Speciallnsp �' �����
Final Dat
Investigotive ee %P — 2Z �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
.. OFRCE USE ONLY This roquest void 18 months 6om I' ion daM printed in this box.
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* 0_6 7 8 7 0 3 0* �.�
PLEASE PRINT OR TYPE
Request Dafe ,. Rough-in inspection required? es ❑ No Inspection Other Than Roughan: ❑ Ready Now ill Call .
C� ��� (You must call the inspecfor when ready) Dafe Ready:
I, icensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address �Sfrcef, Box, or ou No.� � City � Zip Code
(� ��. ��a��r�-
$ection No. Township Name or No. Range No. Fire No. Coun
pant Phone No.
Power Supplier Address
Elechical Con actor (Company Name) � Conhacfor License No. Masfer Lic. No. (Planf Elecf. Only)
CITIFS ELECTRIC, INC. A00381
310G22oTii ^
Mailing Address (Conhacfor or Owner Performing Installafion) �� ��O
^% � •
Authorized SignaNre (Conhacror r ner Perfarning ns ah w���� Phone No.
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E&00001 A-11 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY