P - 78579_ 4 0.� _��� c REQUEST FOR ELECTRICAL INSPECTION
1 � Minnesota Board of Electricity
"°�yr�^ ^ 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
n L —�V ( (651)642-0800T1Y/MRS 1-800-627-3529 www.electricity.state.mn.us
NFW ❑ REMODEL ❑ ADDITION ❑ REPAIR iB@scribe -using theback of the white copy if necessary - the work covered by this request:
ALARM, COMMUNICATION, REMOTE CONTROL,
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
to 12 Units � $50 Per
ach Additional Unit @ :
(II�I IIII) II��I II��I II�II II� �� �� �� (
14053995
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit �$8�
TOTAL FE j � � y-- �
• (minimum total fee is $20 , �
TIIIS AREA FIXt INSPECTOR USE OrLY
I hereby certify that I inspected the electrica� instaMMallon desaibed herein on the d�s sta0ed:
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u t Dffi : Rough-in Inspection Required? ❑ Yes No Inspeclion Other Tha� Rough-In: ❑Ready Now VYdI Call
� You must call Me inspector when reedy! Date Ready: ,
I certify tha I am the �LICENSED CONTRACTOR OCOMPANY ❑ OWNER and hereby request inspection d fhe electrical work at:
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BOARD OF ELE CITV CAPV
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EB-0OOD7Mt4 8.1.2002