P - 78904f Q REQUEST FOR ELECTRICAL INSPECTION
1� 6 4 7��� p � Minnesota Board of Electricity _
1821 University Avenue�Suite S-128, Saint Paul, Minnesota 55104
��q / 6 (651) 642-0800 TTY/MRS 1-800�27-3529 www.electricirystate.mn.us
❑ NEW EMODEL ❑ ADDITION ❑ REPAIR Describe -using the back of the white copy if necessary - the work covered by this request:
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ALARM, COMMUNICATION, REMOTE CONTROt
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
3 to 12 Units �$50 Per
Each Additional Unit �? ;
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
GrcuiLs and Two Inspection Trips Each Dwelling Unit @$80
Fee
TOTAL FEE I �� -
(minimum total fee is $20) �
TIMSMEAFORNSffCiptlbEplY �
I hereby ceNy Ihat I inspeceed Ihe electrical insfaNation described huein on Ihe da0es staled:
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� iai ms on $.31 r Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 M<
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16477283
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ReQuest Date: Rough-in InsPection Required? ❑ Yes No Ins
�_ ` O� pection Oth� Than RougMn: ❑Ready I�bw II Call
You must call the inspeclor when ready! Date Ready
I ceitify ihat I am ttie �LICENSED CONTRACTOR ❑COA�PANY ❑ OWNER and hereby request mspec6on of the electrical work at:
Job Site Mdress (�reel Box`pr�Route y� ,� `� 7�P Code
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License Number
ON BACK OF YELZ�Opy OF ELECTRICITY COPY ..
E&0OOOIMU � 8.7.2002