P - 788831-�028-€398 7�
CIRCUITS OF LESS THAN 50 VOLTS
Unifs � a50 Per
�ditional unit � �
REQUEST FOR ELECTRICAL INSPECTION
Minnesota Board of Electricity _
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651)642-0800 TTY/MRS 1-800-627-352g www,electricity.state.mn.ur
tn Describe -using the back M the w^hite c�opy if necessary - the work covered by this request:
ONE 8 TWO FAM�LY �VELUNGS, EACH UNIT
Includes Ihe Service �d/or Power Supply up to 500 Amperes, All
Cirouits and Two Inspection Trips Each Dwellirg Unit @ a80
TOTAL FEE I �� �
_ (minimum total fee is $20)
��bY�Ytl�a[Ii r�nsu�wrteav�cTOnusEOrar
�D�d Ihe electrital i�sfallatlon Aescribed herein on Ihe dales staBed:
�
� � E
----- °°-• -- �-�-����� ��a.vnneV � tp �F NOT COMPLETED WITHIN 12 MONTHS
IIIII IIIII IIIII IIIII IIIII Illii IIIII Illll N�' i� �� p� �� �����5�
16288987 �
���
��e: ��• O��d�
�_ Rough-in Inspecyion R�uired? Yea ❑ No
You must call tt�e ins �^SP�bn OMer Than RougMn: �Reedy Now O VWI Cell
P�a when readyt Date Ready;
I cerMy that I am tl�e ,� LICENSED CONTRACTOR ❑ COI�ANY ❑ OWNER and hereby request inspecGon of 1he electriql work at:
, .kb Si� Address (Street. Box ar Route No.)
�30 �. rno�o�. �. �
�„ T„�,Q�� �- h�� �I�Oo. � � i
�
Ham L.ake IYN 55�04
��s on e�cK
� t� �
:K K ; , �
� �crnicm coar
��
���� � ������
— �
Mes�r 9ectrician a Poxrer Limiled Tedniciai
Lioenae Numbar
horre (s)
E9-00001M1� 8.7.2aen