P - 80586'^ REQUEST FOR �CTRtCAI INSPECTION
Minnesota Board of Ele ctly
r 1-380-317 �? 1821 University Avenu Suite 5-128, Saint Paul, Minnesota 55104
(651)642-0800 TTYIMRS 1-800-627-3529
www. electricity. state. mn. us
he wark coveretl by �his requesl:
❑ AODITION ❑ REPAIR
CIFCUITS OF LESS THAN 5�
ONE 8 TWO FAMIIY �WELLINGS, EACH UWT
Includes �he Service antl/or Power Suppy up m 500 Amperes, All
Cimui�s antl Two Inspection TriOS Each Dwellinp Uni[ �$80
TOTAL FEE
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Request Da[e: Rou h- ��'sv
g in Inspection Requiretl? ❑ Yes ❑ Insppctbp ORier Than Rough-in: py � w���
oei� �ro� YDU must call the inspectm when readyi � NOW �all
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�"""' "'"" °'�"'°r v uCENSED CONiRACTOR ❑ COMPqNY ❑ OWNER and hereby request inspecAon of the electrical work at:
Job Adaress (Street, Box, or Route No.)
Phone
ipany or Owner Pert
7RIAI �ana
Company ar Owner
OF
ANUKA
Phone
License