P - 78399� REQUEST FOR ELECTRICAL INSPECTION
1� 4 9 4- 0 4 5� Minnesota Board of ElecUicity -
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
r (651) 642-080011Y/MRS 1-800-627-3529 www.electricity.state.mn.us
❑ NEW ❑ REy�ODEL q ADDITIy�N ❑ REPAIR Describe -usinp the back of the white coDV if nece.ssary - the wo� coYered by y�is request:
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
3 to 12 Units �$50 Per Unk
Each Additional Unit � $25
Su lemental Fee $20
Transformers u to 10 KVA $10
Transformers over 10 KVA $ 20
Transformer / Power Su I for Si ns I Outline L' htin $5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service �d/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit �$60
TOTALfEE
(minimum total fee is $20) p� '.��
TH6ARFA FOR INSPECTOR USE 0lLV
I hereby ceNfy that I inspected the elecbical i�talla6on deuribed herein on Ihe da0es stamd:
I IIII II III II II� I� III II III (I III II III II II) IIIII (� �..f
14940456 ��� ` a�SO
Request Date: Roughin Inspection Required? ❑ Yes ❑ No Inspedion Other Than Rough-In: Ready Now ❑ Will Call
���� 03 You must call the inspector when ready! Date Ready. .
I certify that I am the �ICENSED CONTRACTOR ❑COMPANY ❑ OWNER and hereby request inspection of the electrical wak at:
Job Site Address (SVceL Box, a Route No.) City Zip Cade
�--` -� � � / f L vl l� � ` %�� ._ _ �-�,.. ! � �
IN87RUC
- � �. /Ca�,,
( Please Provide Two (2) Phane Number(s) Induding Nea Cade
- ( �- S/�d )
PPlier r�s
Contracror License Number Master Bectrician or Power Limited T dan
ECTRIC: iNC, ����m�
ing Installation)
b5433
Compeny or Perfortning Installadon) Phone (s)
iM BOARD OF ELECTRICRV CAPV EB-0OOO1M14 8.1.2002