P - 78592REQUEST FOR ELECTRICAL INSPECTION
'I � /I �3 ,(1 � o � 4 � Minnesota Board of Electricity -
1 �� v 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
1�� (651) 642-0800 TfY/MRS 1-800-627-3529 www•electricity.state.mn.us
�`
❑ EW EMODEL ❑ ADDITION ❑ REPAIR Describe -using the back of the white copy if necessary - the work covered by this request:
�f� (`%.�Sc� 651— i�I7-7�S
ALARM, COMMUNIGAi WN, KtMV 1 C VVrv i rtv�
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
3 to 12 Units @ S50 Per
Each Additional Unit �'
� I��� I) II� II I�I I! �II II ��I II ��I �I � I� ��� I�
ONE & TWO FAMILY DWELLINGS, EACH UNIT
includes the Service andlor Power Supply up to 500 Amperes, AI�
Circuits and Txro Inspec6on Trips Each Dwelling Unit @$SO
TOTALFEE
(minimum total fee is $20)
TNIS MEA FOR INSPELTIXt 115E pLY
I hereby cerfify that I inspected the electrical inst�la6on described herein on the dates staled:
—•°• ---_ __ ___�___ =�` —
L4300842 �p(.�Q ����
0
Request Dete: Rough-in Inspection Required? ❑ Yes No Inspedion Other Than Rough-In: ❑Ready Now 8'Wi�l Call
� ��(jjtj/,3 You must call the inspectw when ready! Date Ready.
I certiry that I am the �CICENSED CONTRACTOR 0 COMPANY ❑ OWNER and hereby request �spection of the electricai work at:
J� Site Address (SYreel Bo�4 or Route No.) City Zip Code
.�'Sl��{ 7'ennisr�-� �5�- �i;�a��y 5 S�'3.Z
�n VpJda- _ _ �
iplier ���
Cutts'Poia� �► M a�+�!
/ Company
�a�-�in 1 ake. MN 55304
IN87RUC" �ONB ON BAGK OF
I(�63)5�e-�lS ( )
pplier Address
�soo
ConVaclor License Number Master Dectrician a P
�AJ`�^ �/ LicenseNumber
�TV �/ �a
stallatbn)
ing ins i tion) Phone (s)
�aRO �cTwcm coav
EB•00001A-14 8.1.2002