P - 75979REQl1EST FOR ELECTRICAL INSPECTION
1� 9 41- 8 4 9� Minnesota Board of Electricity
1821 University Avenue Suite S-128, Sairrt Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.edectricity.state.mn.us
De.caibe -using tiie ck of the white copy'rf necessery - the work covared by this requast:
/1 .4 � /� � -� _ . . I r i � .l �
� to 400
200 Am re 10 Includ� the Servi� and/or Power Supply up to 500 Amperes, Au
1MMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Two IrrspecUon Trips Each Dwell'mg Unit @$80
CIRCURS OF LESS THAN 50 VOLTS Addi�onal Ins 'on Tri $ZO
ivstem Device or Appaiatus na. $.50 Imestiaative Fee
total fee is
the electrlcai i�taVatlon desm'bed hereN on
Park Lots I
Park Sftes
- O.0 I
4LLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLE�ED WRHIN 12 MONTHS
FOR OFFICE USE ONLY
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�� Rough-in Inspectlon ReqWredl ❑Yes o I
��� nspedion Other Than Rough-In: y Now ❑1Ntll CaII
You must call tl�e inspedor when readyl Date Ready.
I certify that I am the �1 LiCENSED CONTRACTOR ❑ COMPANY � OWIVER artd hereby request inspection of the electrical work at
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Township Sedion Renge Flre No. Coyqty O�
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OwnedOccupant Name Please Rrovide Two (Z) Phorre Numbers Imiudirtg Area Code
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�ar / Company Name � r � - Contredar Liceree Number Master Dec6ldan or
�. .n �_ i � h Ll�nse Number/.9..
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