P - 79940I REQUEST FOR ELECTRICAL INSPECTION
1 18 9 0 6 7 Minnesota Board of Electricity
� � �: 1821 Universiry Avenue SuRe 5-128, Saint Paul, Minnesota 55104
(651) 642-0800 TfY/MRS 1-800-6273529 -
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� www.electriciry.state.mn.us�� .
Itlentify the work coveretl by ihis request
❑NEW ❑REMODEL ❑AODITIINJ ❑REPAIR �/ !/ / !/iA�'(
THAN 50 VOLTS
Indutles the Sernce and+or Power Supply up to 500 Amperes, All
Circuits and Twn Insoeclion Trios Each Dwellina Unit �$8C
total fee is
s�eiem
I IIIIiI IIIN Illll IIIII Illlllllll IIIINNN NII illl FOq �FFICE USE ONLY
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Reques� Date: Rough-in Inspection Requiretl? ❑ Yes ❑ ryo Inspection Ol�er Than Rough-In: Reatly Now � Will Call
�� � � �ou muat call ihe inspector when reaEy! Dete Reatly:
I certity ihat I am ihe ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the elecMcal work at:
Job Atltlress (Sfreet, x, ar�.) Ciy
3 � ZiP Catle
secllon Townsnla •
Range Fire No. Coumv
Occupam "� —�
O � Phone
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or
License
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... BOAND Of ELECTpIC11y �qpy INSTNI1CTId1a n