P - 79963REQUEST FOR ELECTRICAL INSPECTION
1 14 6 2 8 4 Minnesota Board of Electricity
W � 1821 University Avenue Sui[e 5128, Saint Paul, Minnesota 55104 ?
(651) 642-0800 TTY/MRS 1-800-627-3529
' www.eiectricity..slate.ntn.us -
❑REMO�EL ❑ADDITION ❑REPAIR
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ONE 8 TWO FAMILY DWELUNGS, FAGH UNI I
tncWtles me Service andor Power Supply up t� 500 Amperes, All
r:.r�x.....,d r,.,., mmor�inn Trine Fach flwnllino Onii �$8(
toial fee is
on
�3>- 0
FON OFFIGE USE ONLY
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Request Da[e: � Rough-in lispeqion Requiretl? Ves ❑ No Inspection Other TM1an fiougRln: ❑ ReaOy Now Will Call
� O�o� � Vou mus[ cail ihe inspecror wlian reaEy! Oate Featly:
I cetlily ihal I am tlie �LICENSED CONTAACTOR ❑ COMPANY ❑ OWNER aiM hereby request inspection of the electncal work at i
Job Adtlress (SYreet Bw, o� Route Na.7 Citv _ Zio Gotle
2 �;
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Atltlress (COnV [ Gompany or Owne rming Inslellafion) /� /
,�� O�� Tl'�u r(.l' Lv' I'b"]�t►f ,�t.lr� �� ! l
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--BOMUOFELECTRICITYCOPY --- MSTPULl10N30NB11 OFYELLOWCOPY