P - 80201REQUEST FOR ELECTRICAL INSPECTION
1 171 4 0 4 s Minnesota Board of Electricity
� � 1821 Universiry Avenue Suite 5-128, Saint Paul, Minnesota 55107
. - (651) 6d2-0800 1TYlMRS 1-800-627-3529
www,elecfriCety.stqde.mn.us
Itlemity ihe work cavered 6y ihis request: �Q
❑NEW ❑REMODEL ❑ADDITION AS(IEPAIR /'(/{—S 1 /L�T �����J �
YOLTS
ONE & TWO FAMILY DWELUNGS, EAGH UNI I
Ynoludes tl�e Servlce anNor Power Suppty up to 5W Amperea, AA
Cimuitv and Two Insoecfion Trios Each Dwellin9 Unit �$BL
installa�ion
���\
JTHS
rJ� � � � — � ' — — — FOp OFFICE USE ONLY— —
IIIIIINIlllllllllillllll4l141II1l41111lINlllllll �3�� �-�
R/eq/�est �a}te: Rouglr�in Inspeclion RequiretlP ❑ Ves No Inspedion Other TF�an Rough-in: ❑ peady Now ill Call
(` L 0� You must cell ihe inspector w�en reaQ/! Date Ready:
I certify fha[ I am the�] LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of �he elecirical work at:
Jab Address (SVcet, 0ox, or Roule No.) Ciry Zip Code
5'�3c� Ka.U2mE sr F/��/�«� Ssy'3 z
���,���e�
2f S I
� � . _...
��OOOOtA43 Jl112W0
/�,vY/l�i,�
Phone
763 S7i 65.�7
Adtlreas
�C-C�c %�2 / � � ���0/
mpany or Owner Performing Insisilation)
! c L / /��d ST ST/�C
BOAHO OF ELEGTHICRY COPY
O`f.t� S'l 0 8 Z
-Y�S-7i7/
INSTIiVCTION3 d18ACK OF YFLLOW COPV