P - 79951REQUEST fOR ELECTRICAL INSPECTION
1 r18 4 12 8 Minnesota Board of Electricity "
� � 1827 Univereiry Avenue Suite 5-128, Saint Paul, Minnesota 55104
_ (651) 642-0800 TTY/MflS 1-500-627-3529 '
www.electriclty.sta[e.mn.us "�'
ItleMiiy �he work coveretl 6y ihis rtquest: /'1 /� �O `��1` -/i� `�O
❑NEW ❑flEMO�EL ❑ADDITION ❑REPAIR LJ�S �JQ����7C'L
LESS THAN 50
ONE & TWO FAMILY �WELLINGS, EAGH VNII
Indudes 1he Sernce anNor Power Supply up to 500 Amperes, All
Circuits antl 7wo Insceclion Tnos Each Dwellinq Unit � a8C
total tee is $20) ��. S U �
herein an
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FOR OFFICE USE ONLY
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Request ' ^J PougM1-in Inspectlon Required4 ❑ Ves No Inspection Other Then RougRln: Reaty Now Will Call
I� �. �,.{� Vou must cail fie inspeclor when reetly! Oete Reatly:
I cetlify tha[ I am ihe ]�LICENSE� COfJ�RACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrkal work aC
Jab Address (Streeq Box, or qoN¢ No.) _ Ciy ( Zip Ca�B..
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Set1ion Township Range Fire No. Co� ry
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Occupent L Phone
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Ad7ress (Comrado6 Co7�pan or Owner Pertorming I�+ ellatiop
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eC Signalure (ConVacloq Compa or D er Pertorming Installatlon) Phone
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�-13 >I1r`20W BWpD OF ELELTqIqTY COPY INSTqUCTpNS ON BNCK OF YELL