P - 79423REQUEST FOR ELECTRICAL INSPECTION �,�
- I���� g 2 3� Minnesota Board of Electriciry �
1� � 1821 Univereity Avenue Suite fr728, Saint Paul, Minnesota 55104
(651) 642-0800 TTV/MRS 1-800-6273529 ��.�/�°
www.electriciry.state.mn.us _ � �����/���'� "'—` °�a �
Itlentity the W'/otk cover¢d by ihis request ��,v!( ��/ �`��} �. �� C /� � G:�
❑NEW �REMODEL ❑A�DITION ❑REPAIR ! .�i �/.�nl� 1�r� K-P �—w�Lr}— AJi� /jLr�a
Includes the Service anNar Power Suppty up to 500 Amperes, All
total fee is
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FOR OFFlCE USE ONLY
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Requesl Da[e: Roug�-in Inspectlon flequiretl? es ❑ No Inspection Other Than Rough-In: ❑ ReaCy Nav ill Call
o�� Vou must cell ihe inspector when reaEy! �ate Reatly:
I ceRity that I am the ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and �ereby request inspecNon of the elecMCal woAc at:
Jab Adtlress (Sireet, Box, or Rou[e No.) Ciy Zip Code
73�a � �,.c?�9�� ��,� l �, �s�� �--
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Phone
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INSTqUCTIO115 ON BACK OF YELLOW LOPY