P - 78993REQUEST FOR ELECTRICAL INSPECTION
1� 4 6 5� J J� � Minnesota Board of Electricity -
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electriciry.state.mn.us
❑ NEW ❑ REMODEL O�,BDTfiQIC'� REPAIR Describe=usir� the b�ite copy if necessary - the work covered by this request:
0 to 400 Ai
401 to 800
IALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Unil
lill II III II IIl il l!I II III II!!I II II! I! III q� I I�I
14659924
ONE & TWO FAM�LY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 50� Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
(minimum total fee is $20) � �� ,j V
THIS AREA FOR INSPECiIX3 U5E IXJIV
I hereby certify that I inspected the electrical installa6on described herein on the dales staled:
�3310(0
�
ao.5o
Request Date: Roughtin Inspection Required? ❑ Yes ❑ No Inspection Other Than RougMn: Ready Naw ❑ Will Call
You must call the inspector when ready! Date Ready:
I certi(y tliat I am the 'QdICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby �equest inspection of ihe electricai work at:
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Job Site Address ( �px� w No.) / 1 Gty ��� Zip Cod`�_I/� !
n_
� ,�"7,- ( )
ise Number Master Elec6idan or P
License Number
Phone (s) `�
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BOARD OF ELECTRICITV COPY
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E&00001M4 8.1.2002