P - 79472REQUEST FOR ELECTRICAL INSPECTION ��;e,
1 13 6 g 4 4 F Minnesota Board of Electricity
� � 1821 Universiry Avenue Suite S428, Sain[ Paul, Minnesota 55104
.a.�. (651) 642-0800 TTY/MRS 1-800-627-3529
Hnvw.eleciricity.stade.nm.us
Mi/y tAe work covered hy ihis request
�E'IaN�� EX1�CR1o�2 LICrYtTS
NEW �REMO�EL ❑ADDITION ❑flEPAIR 1 ��I1�WCr
to t2
ONE 8 TWO FAMILV �WELLINGS, EACH UNIT
Inclutles ihe Service arMlor Power Suppy up to 500 Amperes, All
Circuits and Two insoection Tnos Each Dwellino Uni� 9$8(
total fee is
THIS INSTALLATION MAY BE ORDEREU DISCONNECTED IF NOT COMPLETEO WITMIN 76 MON7M5
FOIi OFFICE USE ONLY
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Requ�t te: rl ' RougM1-in Inspectlon Required? ❑ Ves Inspeclion Olher Than Roughdn: ❑ Reatly Narv i Call
I�O v Vou must call fie inspeclor w�en reetlyl Date Ready:
I certify that I am the ,�"LICENSE� COMRACTOR ❑ COMPANY ❑ OWNER antl hereby request inspection oi ihe electrical work at:
Job Atltlress (SVeet, Boz, ar Roule Na.) Q Zip Cotle
i�?-I SAcKs�NSrNc �2��t,�-!�
�Sac[�on Township Range Fire No. CounN
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:CTR1C lt�C
ompany or Ownenr Petlo/rtn�in9
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oq Compeny or Owner Pedon
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Contredor License N�
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I /���_ �,fa.w�-� �763-7Bo-g8�� I
EB-OOWlq-13 ]tl2pW BOARD OF F1ECTqIGTY COYY INSTHULTIONS ON BFLK DF YELLOW COPY