P - 774421-729-
I ❑ NEW
REQUEST FOR ELECTRICAL INSPECTION
� 13 � M�nnesota 9oard af E\aclrcaty
�v� 1 g21 University Avenue Suite 5-128, Saint Paul, Minnesofa 55104
� �� (651)642-080011Y/MRS 1-800�27-3529 www.electricity.state.mn.us
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❑ ADqq10� ❑ REPAIR Describe -using the bxk of the white copy ff nec� - the wak covered by this request:
-, ( � n , t,n ✓� l05 � - �1�-1- "-1� � �
CIRCUITS OF LESS THAN 50 VOLTS
31012 Units Q$50 Per Unit
Each Additional Unit @ $25
ONE & TWO FAMILY DWEWNGS, EACH UNIT
Indudes ihe Service andlor Power SuPpIY up to 500 Amperes, All
Grcuits and Two Inspection Trips Exh Dwelling Unit @ S80
TOTAL FEE I h� ,�V
(minimum total fee is $20) , �(
.wsu+� Faa ra�c.oR usE aar
I hereby cert'Ay tliat I inspec�d the electrica� installa0on daaibed herein on Uie dabs staled:
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❑C()NPANY ❑ OWNER �d fierebY �quest insPe�tim of tl�e elBC�ric�l wdlc at� :
E9.00001M11 �&1C2002