P - 76012REQUEST FOR ELECTRICAL INSPECTION
1� p(] p_ p�[� Minnesota Board of ElecVicity
0.7 0 �F J 1821 University Avenue Suite 5-728, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.edech-icity.state.mn.us
Descn'be -using the back of the white coPY if �ry - ihe work coverPd by this r�uegt:
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GENI
/ P0691ER SUPPUES
tM, COMMUNICATION, REMOTE CONTROL, SIGNALING
:UITS, CIRCUITS OF LESS THAN 50 VOLTS
Each Svstem Device or AoaaraWs (iD $.50
Center Pirrot Irrination Baom
THIS INSTALLATION MAY BE ORDERED DISC
I II�I II �� U(�I II I�I � I�I II II) u W Q III uW I�
18984757
ONE & TWO FAMILY DNIELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Ciraiits and Two Insp�tion Trips Each Dwe�ing Unft @$SO
Additional Ins 'on Tri $20
InvesU ative Fee
Reins 'on Fee $20
TOTAL FEE
(minimum total fee is $Z(1) � i �
T W 3 AI�A FOR INSPECTOR USE OtU.Y
I hereby certify that I Inspected the electrfcal histelletlon descrihed herem an fhe dates stat�:
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Fa�? ar�icc usE or���
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2 MONTFfS
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u�: Rough-In InspecUon Required? �Yes ❑ No I �
���� �� nspaction Other Than Rough-In: 0 Ready Nrna WIU Call
You must call the inspedor when ready! Date Ready.
I certify that I am the LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
Jo� ite St�Add �F � s_ ` C� � ��
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Township Section Range Fire No. nty
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HANIVAY ELECTRIC, INC.
27549 128TN STREET N.�A/.
ZIMMERMAN, MN 55398
I�c! T/ ���I � �
nber Master Elec6ldan or P
rLicense Number
Provide Twa(2) Phorre Numbers I
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Technician I