P - 79485, REQUEST FOR ELECTRICAL WSPECTION ,� .
-1 15 5 �� 5 Minnesola Board of Electricify `
� � 7821 Universiry Avenue Suite 5-128, Saint Paul, Minnesota 55104 �
.m.- (651) 642-0800 TTY/MRS 1-800-627-3529 _�
www.electriciry.state.mn.us ' ��'
Identiry the work cavered �y this repuesi: i/'�/1�
�ONEW ❑REMODEL ❑ADDITION jifREPAIR ���� � , V��F/. ��
Inclutles ihe Service anNar Power Supply up to 500 Amperes, All
Cimuitc anA Twn Incner.AOn Trios Each Dwellina Uni� �$B(
�� �.CC ��.�{04 i�i
Iminimum total fee
I hereM ceNN Nat I
z-�.g--d i
FOp OFFICE USE ONLY
IIIIIIIIIIIIIIIIIlIIIIIIIINIIIIIIIIIINIIIItlill �,��9�� 3�,SG�
fiequIes�[ Oate:Q /'� Fough-in inspec�ion Requlred9 ❑ Ves ❑ No Inspection OlM1er Than Rough-In: ❑ Reedy Now � WII Call
O` � � 4��/ � Vou must cell iha inspeclw when reatly! Dete Reedy:
I certty that I am the �LICENSED GONTRACTOR ❑ COMPANY ❑ OWNEfl and hereby request inspectlon of the electrical work at:
Job Adtlrees (Street, Bo or Route NoJ Ciry Zip Cotle
G�Fa �ct_ vr�e Dr, J� �r � ej.l�eu �"s�/.3�
d
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29347
or Owner Perlorming Inslallation)
BCtfIC, I�C.
� Ham Lake, MN 5530a ��s�%�n�
EB OODOtA-13 1/1l2]W BOAHA OF ELE�Y
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3 �.5'7'f -
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INSTXUCTpNS OH BACK OF YELLOW COPY