P - 78798REQUEST FOR ELECTRICAL INSPECTION
� � � ['� ` O [ 5 Minnesota Board of Electricity ` ;
J J 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTYIMRS 1-800-627-3529 www.electricity.state.mn.us
❑ NEW ` 0 REMODEL A 0 REPAIR Descri�-using the back of the whiticopy if neces=ary - the w� cov d his request:
/ j��,
CIRCUITS OF LESS THAN 50 VOLTS
to 12 Units @ $50 Per
ach AddiGonal Unit @ :
( . ` � � ��` IIII�
I I�II� II III IIIII II I���IIIII IIIII II�I IIIII
I I���
1, 7 S 4 0 5 3 5
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit �$80
Additional Ins tion Tri $20 �
Investi ative Fee
Reins cGon Fee $20
TOTALFEE
(minimum total fee is $20) z 6
THIS AREA F01t INSPECTOR USE OtLY
I hereby certify that � inspected tlie elec6ical installa6on described herein on Me dales sfa�d:
wr�
ROUGH IN
FItNL NSPECiION OATE
�.:-� 3_ �-�'�y
pA E
exrx�oina�roorEo
ECTED IF NOT COMPLETED WITHIN 12 MONTHS
. �..�..�...i��w�i
2 �`��
o2.a • Sd
Requesl Date: Rough�n Inspection Required? ❑ Yes No Inspedion Other Than Rough-In: y Now 0 YYII Call
6„3aQ3 You must call the inspector wh� ready� Date Ready:
I certity that I am the ❑ LICENSED CONTRACTOR ❑COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Site Address (Street, x. or Route No.) City Zip Code
,�.,., �,sr ..� .,.�., n., FRiT'1i.F
KOVAR ELECTRIC LLC
i�ing address (cono-aa«, canpany or owner Pe�
23049 ARROWHEAD ST NW
�,�.,� r,x, r�trector. Comnanv or Owry
iNStnucnons or� ewcK
Mas� �ecv�cian or
License Number
MN 55070
�- I 763-753-5731
eo�o oF e�crniciTV coPr es�0000+�-ia e.�. zooz