P - 79939REQUEST FOR ELECTRICAL INSPECTION
1 J�� � O^ Minnesota Board of Electricity
�' j � c� 1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104
(657) 642-0800 TTY/MRS 1-80d6D-3529 =
wrvw.elec(ricity..sfate.mn.us .
ItlHItIFj t�e work waeretl by 111�5 fe0u¢st: /
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❑NEW ❑REMODEL ❑ADOITION ❑REPAIR
Includes ihe Service anNOr Power Supply up to 500 Amperes, All
iuin� ree
total fee is $201 30_ sd
_�
;(IIIII lllll lilll {IIN II111111811IN IIl I IIII IIII ��FICE USE ONLY
N i� 1 1 8 9 � 4 D�c �, f% 57 ,� 30iJ`YO
� �� � ��� �A � I You mus� call the inspector when reatly� I D t R tly� I
I ceNty ihat I am the � LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspeclion ot ihe elecirical work aC
Job Address (Sireet, Boz, or Route No.) Ciry Zip Cotle
2�l1 Vah c�e. f. 1 i,r/� 1e� SS/�3-?
tieciricgl Gontractar / Compeny Name
n �'
Maili 1O�tlress (COMrectorq, Co�mp�a�rry �or
'l�j( �-C/(T/�
Authonzetl Signe ractor, Comper
�EB�O0001q-13 ]/1/2p00
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Atltlress n �
OF ELECLIiICITY fApY
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