P - 83967I 49.��-970
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REf�UEST FOR ELECTRICAL INSPECTION �-�.
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
Other. ew Addn
Indushial Farm moc
tg. Equi . Water Htr. Load Mgmt. Other:
ange f� Elec. Heat Temp. $ervice
covered by this request. Enter remarks in this space and on ►he back of the white copy
Calculate Inspection Fee - This Inspe
Other Fee
Mobile Home Park Stall
Street Ltg./Traffic Sig.
Tra nsformer/Generator
Sign/Oudine Ltg. Xfmr.
Alarm/Remote Control
Swimminq Pool
m Request will not be accepted without ihe correct fee:
# Servic Entrance Size Fee # Circuits/Feeders Fee
to 6 Amps 0 to 100 Amps
Above 200 Am s Above 100 Amps
INSPECTOR'S USE ONLY IpTAL C�
p ��____
��
I hereb certi that I ins the eletlri 'nstallation described herein on the dates stated
RougMn pat� Js i� �
Investigative Fee ��� � ��_ �� �,
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLV This requesT void 18 monihs from validation date printed in fhis box.
��������I���i�lli��l��� ��oy� s
IIIII IIIIIIIIIIIIIII
* � 4 9 8 9 7 0 3�k PLEASE PRINT OR TYPE 7�' ��
Requesf Dafe Rough-in inspection required? Yes ❑ No Inspeclion Other Than RougMn: ❑ Ready Now Will Call
t`— a (You must call the inspecfor when ready) Dafe Ready:
I, censed contractor ❑ owner hereby request inspection of the above electrical work at:
lob Addreu �Streef, Box, or Route No.) Cily Zip Code
� y s s c�-1-�� sT�e-�. se�. L� ��,� b c.�e
Secfion No. Township Name or No. Range No. Fire No. Counly
��� i
�� Phone No.
�r..�, t� S�
Conhacfor �Company Name�
CITIEv F�ECTRIC, INC.
�ddress IConhacfor or ^er Pe �fiil{-a
w .�
Conhactor License No.
CA0038�
�°°'2564 �
Masfer Lic. No.
No.