P - 79264REQUEST FOR ELECTRICAL INSPECTION
1 3 21 0 4 0 Minnesota Board of Electricity
� � 1821 Universiry Avenue Suite S-128, Saint Paul, Minnesota 55104 z ?
^ (651) 642-0800 TTY/MRS 1-800-6273529 -
www.electrrciry.state.mn.us
Itlentify ihe woM covered by this request: / Q
❑NEW ❑REMODEL �A�DITION Yd1ihPAIR ��.���� ��i����
OF LESS THAN 50
Inclutles ihe Service and/or Power Suppy up ro 500 Amperes, All
total fee is
f.l�/_ C/—l7—os.
ins�slla�ion tlewribed herein on ihe
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18 MONI
—� ____ _. . _. __. . . FON OFF�CE USE ONLY �_
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Requesl Date: ^ Rough-in Inspection Requiretl? ❑ Ves o Inspectan O�her Than Pough-In: eatly Now � Will Call
' l ' l� � Vou must call iha inspector when reatly! Oe[e Reatly:
I cenify ma( I am Ihe ICENSED CONTflACTOF ❑ COMPANY ❑ OWNER and hereby request inspection of the elecincal work at:
Job Mtlress� a4 Box, or Roule No.) 1 _^ thy _� , �i J Zip Cotle
Occupant
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