P - 80454� � REQUEST FOR ELECTRICAL INSPECTION
.....
� ' � Minnesota Board of Electricity �'
1-381-441 � 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY(MRS 1-800-627-3529
www.e%ctricity. state.mn. us
Identify the work covered by this request
illtlEW Q REMODEL ❑ ADDITION ❑ REPAIR x�E� ENERGY �AVER�S SWITCH
to 800
0
ALARM, COMMUNICATION, REMOTE CONTROL,
CIRCUITS. CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or Ap aratus �$.50
ADDITIONS TO THE GENERAL F
MULTIFAMILY DWELLINGS PER UNI�
3 to 12 Units �$50 Per Unit
Each Additiona� Unit � $25
OTHER ADDITIONAL FEES
ONE & TWO FAMILY DWELLINGS, EACH UNIT
includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit �$80
Additional Insoection Tri�s � $20
TOTAL FEE
d fee is $20)
FpR INSPECTOR USE DN�V
I hereby certify that 1 inspectetl Me electncel instellation descnbed herein on the da[es slated:
ROUGHIN � DATE�
FINAL INSPECTION Q /� DATE
/ Cz-�
FOR OFFICE USE ONLY
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* 1 381 441 3* c'1�%�
Request Date: Rough-in Inspection Required? ❑ Yes ❑ o Inspection Other Than Rough-in: eady Now ❑ Will Call
Q$��1 You must call the inspector when ready! Date Ready:
I certify that I am the LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Address (Street, Box, or Route No.) City Zip Code
25 fsP,1/2 WAY NE FRI[iLEY 55432
Section Township Range Fire No. County
� ANaFtA
Occupant � - Phone
HOVE SUZANNE Y
Power Supplier Address
Electrical Contractor / Company Name Contractor License Number Master License Number
MaNing Address (CoMractor, Comparry or Owner Performing Installation)
23QQ TERRITORlAL ROAD SAIIVT PAU MN 55114
Authorized Signature (Contractor, Company or Owner Performing Installation) Phone
EB-OOOOtA-13 7/1 000 BOARD OF ELECTRICITY COPY INSTRUCTIONS ON BACK OF YELLOW COPY