P - 79450REQUEST FOR ELECTRICAL INSPECTION ��
1 19 9 8 2 7 Minnesota Board of Elechicity `�
� � 1821 University Avenue Suite 5-128, SaiM Paul, Minnesota 55104
_ (651) 642-0800 TTY/MRS 1-800-627-3529
x�ww.electriciry.state.mn.us .
Idently Ihe wark cmered by this request �T �3
❑NEW ❑REMODEL SfAD01TION ❑REPAIR LI%IILLf .I�C1�Ltf .�QCL�T/B.aJ (�t✓ao�r_
CIflCUITS OF LESS THAN 50
ONE & TWO FAMILY �WELLINGS, EACH UNIT
Includes tAe Service andlor Power Supply up to 500 Amperes, AIl
Cirr.uds antl Two InsnMinn Tnos Each Dwellina Uni� �$8(
total fee is
tlescnbetl herein on
Z �.� '
2 �'
THIS INSTALLATION MAY BE ORDERED DISCONNECTEU IF NOT COMPLETED WITNIN 78 MVN7M5
FOR OFFICE USE ONLY
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IRequest Da : Rough-in Inspection Requiretl? Yes ❑ No Inspection O�her Than Rough-In: ❑ Reatly Now � Will Call
.� 3 O/ Vou must can rtre Inspecm� when reatlyl �ate Ready:
I ceRify ihat I am ihe �LICENSED CONTRAGTOR ❑ COMPANY ❑ OWNER and hereby request i�spec6on of the elec[rical work at.
Jab Adtlress (S�reet, Boz, or Route No.) Ciry Zip Code
� /✓I LA.e/L� �Y����C �
SMion Township Range Fire No. nry
L- ,Lr/� e 7
ess (COntracmr. Comoanv or
Phone
-J75�7
- L''rtir c.✓ G.� ✓ � �� � i
Wre ontra pany or Owner Pertorming Installation) Phone �
�G3-S��/-S'T/1'
2 BOAND OF ELECTqICITY COPY INSTFU4TIONS ON 9RCN OF YI