P - 83143,1 REQUEST FOR ELECTRICAL INSPECTION =
5�a�.1 p� 0 Minnesota State Board of Electricity
• 0 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 ir
ir Cond. Htg. i. Water Htr. Load Mgmt. Other.
Dryer Range /( Elec. Heat Temp. Service
"X" above the ork covere y ihis request. Enter remarks in this space and on ihe back of the white copy only.
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Se ' e Entrance S'z Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 0 Amps 0 to 100 Amps
Sfreet Ltg./TrafFic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOT C�
Sign/Oudine Lig. Xfmr. G� � S'�
Alarm/Remote Conhol
Swimming Pool
I her cerfi tlwt I in Ihe electrical insMllation dexribed herein on Ihe dates stafed
Irriqation Boom R,,,�,�„ . _ � .� �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE l�E ONLY This roquesf void 18 months (rom validafion date printed in this box.
I -I''I � 7S,SZ>
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* � 5 6 6 9 8 3 3�Ic PLEASE PRINT OR TYPE
R�u1��( Q� Rouglfin inspeclion required$ Yes ❑ No Inspeclion Olher Than RougMn: ❑ Ready Now �II Call
V �(� $ (You must call the inspector when ready) Date Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
1ob Add� (�eet, Box, w No.) � City � Zip Code
r1 1 ��', �Y'7 CQ i
SecFion No. Township Name or No. Range No. Fire No. Counly ^
1� ��� A
I Power
racFor �Company Name)
CITIE3 ELECTRIC, INC. CA00381
u�Conhacbr or ner e a� ns0' �n 5�
� p -3
w �
Pfione No.
Ca�hactor License No. � Master Lic.
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11 8/96 �p� gOARD COPY - SEE �STRUC710NS ON 6ACK OF YELLOW COpY