P - 79580RE�UEST FOR ELECTRICAL INSPECTION
1� 13 9-16 6 Minnesota Board of Electriciry
7821 University Avenue Suite 5-128, Saint Paul. Minnesota 55104
� �^ � � (657) 642-OS00 TTYlMRS b800fi27-3529
( www.electriciry.state.mn.us '�-"'-�
Identiry the work coveretl by this request: p �� ����p
�W ❑REMODEL ❑ADDITION ❑REPAIR ��",���ULfY�'/� ��""Y� 4I`�
CIRCUITS OF LESS THAN 50 VOLTS
Inclutles the Service anNa Power Supply up to WO Amperes, All
Circuhs and Two Insoection?nos Each �welling Untl �$8(
total fee i5
I herebv ur1iN ihal I insoecletl Ne elecVkal i/blalldtlon d25CnbEd herein on Ihe d01as 41aMtl:
U�—�
FOR OFFICE U8E ONLY
III�I�I
I ceniry that I am the �'[CENSED COMRACTOR ❑ COMPANY ❑ OWNER antl hereby request inspection of ihe elecincal work at:
,bb Atltlrass (5[reet, Box, or Roufe No.) Ciry 2ip Code
AtlOress
!
� Mailing Atltlress (Contraclor, ComOenY or
Phone
r-7-cw i
INSTPOC90N6 ON 9�GII OF YELIOW COPY