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Home Duplex
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"X" above the work
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 Universiry Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
Farm
Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
this request. Enter remarks in this space and on
Calculate Inspection Fee - This Inspection Request will not be accepted without the correcf fee:
Other Fee # ice Entrance Size fee # Circuits/Feedi
Mobile Home Park Stall 0 to 00 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100
Transformer/Generator INSPECTOH'S USE ONLY TC
Sign/Outline Ltg. Xfmr. (�/S
Alarm/Remote Control
Swimming Pool
Remod
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Fee
I hereb certi fhat I ins ected the elecfrical insfallaKon described herein on the dafes sMted
IrrigatiOn Boom Rough-In Dare
Special Inspecti ���'�- � ' �' �
Final fe
Investigative Fee —/.���
THIS INSTALLATION MAY BE ORDERED DISCONNECrED IF NAT rniuvi FrFn w�TUw ,a unuTUC _
OFFlCE USE ONLY This request void 18 months from validation ciate printed in fhis box.
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Request Dafe ^� Rough-in inspection required? s ❑ No Inspecfion Other Than Rough-In: ❑ Ready Now ill Coll
t�,'� 7 (You must call the inspector 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
Coy �7 C°_�n�sr � �.a...� �i2r bc�e
Section No. Township Name or No. Range No. Fire No. County .
Occupa
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Power Supplier � � ^
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Elecfrical Conhactor (Company Name)
CITIES FLECTRIC, INC.
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Mailing Address �Contracfor or Owner Perf�
n . 0 � ..
CA00381
�e7rle ��
Phone No.
icense No. Master Lic. No. (Planf E
Phone No.
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