P - 79256� REQUEST FOR ELECTRICAL INSPECTION
1 2 7 8 717 „� Minnesota Board of Electricity
� � 1821 Universtty Avenue Suite 5-120, Saint Paul, Minnesota 55704
�-+a- (651) 642-0800 TTY/MRS 1-800-627-3529
www.efectr'iciry.sm[e.mn.us
❑ REPAIF
Ixludes ihe Service antllor Power Supply up to 500 Amperes, All
Circuits antl Two Inspecfion Trips Each Dwelling Unit � 50[
THAN 50 VOL
FOR OF:ICE USE ONLY
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total fee is
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I`' �" 2 Q�V � I Vou must call Ihe inspector when ready' I D t R tly i' �ij " Y� � I
I certiry that I am 1hQJa�.LICENSED CONTAACTOR ❑ COMPANY ❑ OWNER aM hereb re
y quest inspecfion of Me elecMral woAc at:
Job Atltlress (SVeet, Boz, o� Route No.) Ci[y Zip Code
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ss (COMraclor. Com�n-or Owner PeNOrming
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7nature (COmr q Company or Owner Pedor
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Phone
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BOAHD OF ELECTpltrty COPY
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INSTPIICTIONS ON BACK OF YELLOW COPY