P - 79364REQUEST FOR ELECTRICAL INSPECTION
1 � O 2 9 01 Minnesota Board of Electriciry
d � 1821 University Avenue Suite 5-�28, Saint Paul, Minnesota 55104
. (651) 642-0800 TTY/MRS 1-800-6273529 � �� �
www.electnc�ry.state.rreaus
IOentify ihe woAc covereU by this request: ���� �`Q ,„'� �'` ��
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❑NEW ❑REMODEL ❑AODITION �t+EPAIF
Inclutles t�e Serv�ce anNor Power SuOPIy up ro W� Amperes, NI
cimuns ann Twn Insoectian Tnos EaCh Dwelling UnA �$B(
OF
THIS INSTALLATION MAY 8E ORDERE� oISGONNtI:I I
, . _._ _._. __ _ _. _ .--. ' FOp OFACE USE ONLY
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I Requefl Date: I Rough-in Inspectim HequiretlP LJ �es � No I InspecnOn Umer i nan nougn-�n: �eaay rvow U w"' �an I
Vou must W I me inspeclor when reatly! '\ Date Reatly:
I cetlity ihat I am ihe �LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby requesf inspection of �he electncal work at:
Job P.tltlress (Slreet, Box, or Route NoJ Ciry Zip Cotle
�33f., P�r rt��2A RD� FRtD�
� Occupent _ ,�
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Phone
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60M� OF ELECTIiICITY COYY
' '"ZD f"LO 6 / I
INSTHUCTpN3 ON BPCK OF YELLOW COPY