P - 79260REQUEST FOR ELECTRICAL INSPECTION
1 3 5 4 2 8 7 MinnesoW Board of Electriciry
� � g 1821 University Avenue Suite 5-128, Saint Paul, Minnesofa 55104
x:"y� (651) 642-0800 TTY/MRS 1-800-6273529
www.electricitp.state.mn.us
❑REMOOEL ❑ADOITION
LE55 THAN 50
over
ONE & TYYO FAMILY �WtLLINGS, tAGn UNn
Includes ihe Service ardlor Power Supply up to 500 Amperes, All
Circuits antl 7wo Inscemion 7rios Each Dwelling Unit �$e(
FOH OFFICE USE ONLY
�I ����*I�)
fotal fee is
`��
�#(�/�1�v
�8. 5O
I ceNy that I am fhe �LICENSEO COMRACTOR ❑ COMPANY ❑ OWNER and hareby requesl inspectlon of the electrical work at:
Job Atltlress (S�ree( Box, or Rwte No.) Ciry Zip Cotle
l3// // e s f�: vr /�_ �r ,` oi/�f .h—�-�3�
Uahre,/
Power Supplier
X e/
Electncal rXreclor / (
pJ /G �
Mailing Address (COntn
�„no�
�-I.h✓ �G
Atltlress
i s'�
ipany Neme
IeG � C�
iq Canpany ar Owner Petlorming
�� c 5 f
Irq , Compa or Owner Parfor
,o,.� „r� h c ,��.
P�ore
f a�- �-a3 � �--
�� C�i�sfnu���' /� ls/�i�
Con ctor License Number Maste License umber
��-d 0 9 0�
Installa�lon)
�'1i E ' {�l I S /'i7 N ,S-S �/j-3
ming Installetion) Phone
l�1�--37�—1 �03
BOPRD OF ELELTflICITY COFY INSTHUCTIONS pi BO.CK DF YELLOW COPY