P - 795921-139-169
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Itlentiry ihe work caveretl 6y this request:
RE�UEST FOR ELECTRICAL INSPECTION
Minnesota Board of ElectriciTy
1821 Universily Avenue Suite 5-128, Saint Paul, Minnesota 55104
�ssi> saz-oeoa TTYiMRS i-800-627�529
www.electriciry.sta[e.mn.us
1f�NEW❑REMIODEL❑ADDITION❑REPAIlisl"�'�R��'",_ " /���^`
Indudes Ne Service anNor Power Suppy up [0 500 Amperes, All
Circuits antl 7wo Insoection Tnps FacA Dwellino Unit �$8(
FOIi OFFICE USE ONLV
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total fee is
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Raquest Dqate:/� qougMin Inspection Feq�iretl? e%s ❑ No Inspection 01�er Than Rough-In: ❑ Reatly Now ill Call
2� L(/ "�t Vcu must cell the inspeqor w�an reatlyl Dete RaeOy
I certify ihat I am the �CENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby requesi inspection of the electrical work aC
Job Adtlress l��ee4 �x, w Route No.) CiN nn r ne
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ortnyppr Periorming Installation)
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