P - 79409I. REQUEST FOR ELECTRICAL INSPECTION
�� 3 0 5 9 7 6 Minnesota Board of Eleciriciry
y � , a-' 1821 Universiry Avenue Suite 5-128, Saint Paul, Minnesota 55104 �'�_
(651) 642-0800 TTY/MPS 1-800-627-3529
www.electricity.state.mn.us
I Identity the wo�k coveretl by tfiis �equest: ,U
•�'•.�� /�' � � (.�.�u.�..�i`��C'�i
. NINEW ❑REMODEL ❑ADDITION ❑qEPAIR
ONE 8 TWO FAMILV DWELLINGS, EACH UNIT
IncWtles the Service a�a Power Suppry up to 50D Amperes, All
Circuits and Two Insoection Trios Each Owellina Wit �$80
I��II�� I���� ����� ����� �II�� 1��1 ����I I���� �I�I ���� OFFICE USE ONLY
��
total tee is
�
,� 5803
de,so
I /V ���'� � I You mast call ihe' . y.__ �.•V �y��,� V��"r rmn nougn-in: IA R¢pdY Now � WII Wll I
��
pecb h tlYl � 0 t R ay
I cedity thaf I am ihe � LICENSED COMRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Aetlress (Sfreet, 8ox, w Route No.) C��,
�i/ g � Zip Code
'r� ' e f C; i� /e� Gr.�J/c 33'�3.�--
Sectlon iownship Range FireNO. CW�,
OvtuPant/ i/ .. . Phon�n[� ��/`/
Atldress
i �s-��r ,� ,
U/,�s f.-�� � f�i
ctor / Cortpany /Name ConlraIXOr License Number Masler Licens Nu
r �iI�C��%/ L
�/'f%i fi %Ti G�
(Contracloq Company or Owner Perfo�ming IOSfallationJ
i Ii -S' %�,rL /�l !S %�� �3'�/�
lu ConlracN peny or Owner Performing Installaiion
Pp/ane l
C�� �o� � � �� �
BOAPDOFF}EC1q�CrtYLOPY WSTpUCTpN50N
/S ,�N� I I
z�
ve�u