P - 78053REQUEST FOR ELECTRIC/AL INSPECTION
1— 5 4 5� 2�� � Minnesota Board of Electriaty y ��
1821 University Avenue Suite S-128, Sai�Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
❑ NEW REMODEL ❑ ADDITION ❑ REPAIR Describe -using the back of the white copy if n essary - th covered by this request:
�v�l..�.,— 1�v..��a� +—� �1 C"��n ar 2,� �`' �c� �,rr.f' C�
ALARM, COMMUNICATION, REMOTE CONTROt
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each Svstem Device or Aouaratus f� $.50
3 to 12 Units
Each Additio
Standard
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
CircuiLs and Two Inspec6on Trips Each Dweliing Unit @$60
/ TOTALFEE
(minimum total fee is $20) � �,'� i�
iMS,VtFA FOR I!N{CTpi USE OIIY
I hereby c�5(y tl� I inspec6ed the elechical instapa6on described herein on the dates sfaBed:
Hour
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15452774 � �6
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��� Rough-in Inspecfion Required? U Yes ❑ No InspeUion Olher Than RougMn: ❑Ready Now � WNI Call
�� J� l� � You must call the inspector wAen ready! Date Ready:
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I certify that I am ri�e ❑ LICENSED CONTRACTOR 0 COA�ANY ❑ OWNER and hereby request inspeciion of fhe electrical work at: