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P - 84548� � / � � ; I - REQ�EST FOR ELECTRICAL INSPECTION Minnesota State B�a''Rm S 12S �gt. Paul, MN 551oa 1g21 University Ave., Phone (612) �2-0800 rle ,,,„�� ;r: ; ' r # '- sl. �' wpMIPLETED W11^'--'=--"� CTED �F N�T C--'--� rinted �� th�s bo� N�'�NE ��hs from validation dare P pFF10E USE OM�� This re9uest void � 8�^O ��/ ,_% r� f7� � S,� ��b� IIIII ASE PRIN7 OR NPE Ready Nov :•'" I�III� LE ❑ �I�II� P o� Mi�. �i . an R 9 �IIIIIII'' * ion 01her 7F� �III�II � �j( Ins II"III� 5 3 No � * 0 4 �j 7 � 2 ❑Yes P� pateReadY� tion re9�'r�' RougFrin insp� tor wheo ready� UY: yquest Dat �j�� `% C(ou must call ihe insp� j / 04 the above electrica wor Z,P C�e ( l% f p req�est inspe�tion owner hereby c�y �., � �"�,licensed contractor ❑ �,2 � � � � Street, Box, or Route No.)_ �� /, 7; { C Co�nb �� rv Job Address ( �� / e No. Fire No� � � � Rang I '�,"'l� �, .,_ n�.,me or No. phone No. , j�� r � s�+�o� ��. _ C��c" C1✓v, o�.��t �u �� Address pa�yer Supp��g� � 1 Conhactor (Compo^Y NO�"e� Eledr 4 � � � L � �' L J�`� ��,o�acror or Ow^er Perform'ng losta °^� � .._a:.,,. Address ( _ n Il �% � � �� G� . �) cau .,� � _ � _�?� p/wster Lia No. �P�ant Elect. O Jo. b � � f� z �i � � Phone N°� r�� l o'L � e� tallation) i F '.,' `-' � t YELLOW COPY � pY - SEE INSTRUCTWNS W� BACK � STA'� BOARD �