P - 78781� REQUEST FOR ELECTRICAL INSPECTION
��/� Q 1� 7 3 � Minnesota Board of Electricity :
`•t V �� 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
�� � (651) 642-0800 T"fY/MRS 1-800-627-3529 www•electriciry.state.mn.us
❑ NEW REMODEL 0 ADDITION ❑ REPAIR Describe -using the back of the white copy if necessary - the work covered by ihis request:
r�„� �l,-f _.4� �� CG-sI) `7�]��?���
ALARM, COMMUNICATION, REMOTE CONTROL
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
$50 Per
U�I� � �
III�I��III (I�II IIIII IIIIIIII�I III�I I�III �� ��
1487373L
to 10 KVA @ $10
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes� Ail
Circuits and Two Inspection Trips Each Dwelling Unit �$BU
Addition� Ins tion Tri $2(1
Investi ative Fee
Reins tion Fee 820
TOTAL FEE lJ c �
(minimum total fee is $20) v� �
TMS ME� FOR NSPECTOR IbE 0llY
� �ICfE� (�� i�12I � I�SpEC� �1C C�CCCU�L2� IIIS��OfI ��� �EI11 OII d1E d2�5 S�:
OATE
ROUGH Xi
WTE
�AtNSiFCTION r QI
F1�0/
ECTED IF NOT COMPLETED WITHIN 12 MONTHS
� �`��O a0-SO
Request Da�te�:/ Roughin InspecGon Raquired? ❑ Yes Q�Fb tr�peclion Other Than RaigMn: ❑Ready No+v�ll Call
���"�/ ' Q� You must call the inspeGOr when ready! Date Ready.
I certify that I am the ,�ICENSED CONTRACTOR ❑COMPANY ❑ OWNER and hereby riequest inspection of the electriczil work at: