P - 79717` °" "- UEST FOR ECECTRICAC INSPEL�1`�N �
1. � 14 3- 5 6 5; M���eso�a Boaro o, E�e�«���ty
1821 Universtty Avenue Smte S 128, Saint Paul, Minneso[a 55104
(651) 642-0800 TTYlMRS 1 800 627-3529
www.electricity.state.mn.us
wofk coveretl by �his request
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�PEMODEL ❑AODITION ❑REPA�R
Includes the Service anNor Power SuppN up to 5�0 Amperes, All
CircuBS antl 7wo Inspeciion Trips Each DwefGng Un� �$8(
FOR OFFICE USE ONLY
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I cerlity that I am 1he�CENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspec�ion of the electdcal work at
Job Atltlress (Sireet, Box, or Route No.) Ciry Zip Cotle
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Elec1ncal Conhecto� / Company Name Conhector Licens
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INSTXUCTONS ON BALK OF YELLOW COPV