P - 79488r, REQUEST FOR ELECTRICAL WSPECTION
1 � O� �� O Minnesota Board of Electriciry
� � 1821 University Avenue Suite 5-128, Sainl Paul, Minnesota 55104
w, �ssi� saz-osoo TTY/MRS 1-500-6273529
www.elecKicify.state.mn.tes -
Itlentiry ihe work covered 6y tAis request /�
❑NEW �REMODEL ❑ALIDITION ❑REPAIR ' ' ��� � ����
ONE & 7W0 FAMILY DWELLIIVIiJ, tAOM UNI I
InGUtles Ne Service andlrn Pawer Supply up t� 500 Amperes, All
Circuits antl Two InspeNOn Trips Each Owelling Unit �$BC
THAN 50
a-
Sd
� � PoR OFFlCE USE ONLY
IIII�I�II�III�I�II��III�I�IItI7�iII�I�II�IIIII1lIl
* � � o � �� o�* ,�69?y �,s'o
Repuest D e: Rough-in Inspeclion Requiretl? Ves ❑ No Inspection Diher Than Rough-In: ❑ Ready Now � Will Call
� "Z ��� � You must call Ne irtspector when reaQyl Date Ready:
I certify thai I am [he �LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspedion of the eledrical work aC
Jab Atltl�ess (Streeq Box, or Fiaute No. Cily 7�p Cade
66-5 ,S9r�r- �v� �. f. �'-,2�o�„�j'
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Occupant
C'.�� (fA�,B�eG
�v�,uG ��,��r �
Itlress (Coniractoq Company or Owner Pertorming I
�a� !�°'x 7e7 d� -ST.
I S'gneN (COM/rador, Co� or 0'aner Pedo
Z/
3 �nn000
Phone
�63 -�7f - �4 7 `f
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Comradw License Number Master �icense Number
C,¢OO 73�,
nstalla�ion)
c�3 /JfN SSo ��
rming Instal�aGon) Phone
�3-�s�_i�sa
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