P - 78767REQUEST FOR ELECTRICAL INSPECTION
�� 2 I_ 7 6 q, � Minnesota Board of Electricity
�t 1821 University Avenue Suite S-128, SaiM Paul, Minnesota 55104
(651) 642-0800 TlY/MRS 1-800-627-3529 wx'w•electricity.state.mn.us
n NFW REMODEL 0 ADDITION ❑ REPAIR Describe -using the back;f ffie white copy if neces� - the work covered by this ;q;est:
CIRCUITS OF LESS THAN 50 VOLTS
3 to 12 Units �$50 Per
Each Addi6onal Unit � �
IlII IIII) II�II I�III III�I IIIII (III� IIIII ��� I�
1 4 2 7 7 6 4 4
ONE 8 TWO FAMILY UWt�un�a, rr�.n vi.� �
Includes the Service andlor Power Suppiy up to 500 Amperes, All
Circuits and Two Inspec6on Trips Each Dwelling Unit � E�
TOTAL FEE SU
(minimum total fee is $20) ��'
THIS APEA FOR MSFECTOR USE OfIY
I hereby cer6tY � I inspected the electrical ir�fallaUOn desaibed herain on the da�s sh�ed:
2��
�`�$g
�038'�0���
Request te: Rough-i� Inspection Required? es ❑ No Inspedian Other Than Rough-In: OReady Now 0 NAII Call
a, You must call lhe inspector wh� ready! Date Ready:
I certiiy that t am ihe I�LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the elecUical work at:
Job Sife Address (SVeet, Box. a No.) City Zip Code
i,�� s�e S�: � i D L�1
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ON BACK OF YELLOIN CO� BOARD OF ELECTRICITV CAPV
(bs13o��7&`1b� >
nse Number Mast� Electrician or Pcwer Limited TeC�nid�
,y �� License Number
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e � .�50
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E9-0OOOtM14 8.1.2002