P - 79439REQUEST FOR ELECTRICAL INSPECTION
�191 6 0 7 Minnesota Board of Elect�icity
� � � 1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104
X�� I _ (651) 642-0800 TTY/MRS 1-800-627-3529
www.elecaricity.state.rnn.us
Itlemity the wark cavered by ihis repuest: � /� - /�
❑NEW ❑REMO�EL �ADDITION ❑REPAIP � � �� /J �� Y,e� CL �
Inclutles ihe Service anNOr Power Supply up to 500 Amperes, All
Cimui�c and Two Insoection Trios Each �wellina Unit �$8[
OF LESS THAN
FOR OFFICE USE ONIY
l IIIIII IIIII IINI Illll IINI IIIII Illll IIII I IIIIlIN
Request Date: _ _ Rough-in Inspection Repuiretl? ❑ Yes No
total fee is
,e�G 53��0 <sc7
er Than Rouqh-In: I-1 ReaM Now
I �� �'�] ��J i � You must cell ihe inspec�o� when readyl � Da[e ReaGy �
I cebty that I am the �LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspecNon of the electriral work at
�a
i
QS ��t
—fAtltlress
Phone
�(�� • S%�/ Z'�'�
� W
v aw� Pa� �e ��s,��a����M. 5 10 7
� i.l 5
�any or Owner P rming Inslallaeon) �Phone �
� r,�.Q..�l �.Ql,c� I(.P� r' n�� ��
BOAHO OF ELEGTHICrtY COPT INSTqIICTONB ON