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IUentiy ihe work coveretl by this requesL
❑NEW ❑REMODEL ❑ADDffION
THAN 50
REQUEST FOR ELECTRICAL INSPECTfON � m
Minnesota Board of Electricity -.
1821 Universiry Avenue SuRe S-128, Saint Paul, MinneSOW 55104
(651) 642-0800 TTY/MRS 1-800-6273529 �`
www. elec[riciry. state. mn. us
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ONE & TWO FAMILY DWELLINGS, EACH 11N1T
IndWes ihe Service anNor Power Supply up to 500 Amperes, All
Cimuits antl Two Inscection Trios Each Pwellina Unit �$8(
FOfi OFFICE U9E ONLY
I IIiNI IIIII ICIII illll illll IIIII IiII�NlII Ifll III
Reque/st Date: Rough-in Inspection Repuiretl? ❑ Ves No
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total fee is
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/ Vou mus[ celi the inspector when reatly! � Date Reatly: //�� / �
I cedity that I am ihe LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspectlon of ihe electncal work at:
Job Atldress (Sireet, Boz, or Rf u[a No.�j r Ciry � Zip Cade
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