P - 76137REQUEST FOR ELECTRICAL INSPECTION � �'
1- 9 3 6� 4 6 9� Minnesota Board of Electricity ,
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
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(651) 642-0800 TTY/MRS 1-800-627-3529 www.edectricity.state.mn.us
D -using the baeKof the white copy if nec�ssary - the work covere�i by this request:
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)MMUNICATION, REMOTE CONTROL,
CIRCUITS OF LESS THAN 50 VOLTS
ivstem Devic� or Aoaaratus id. $.50
I MUL'
Transfortners up tc
Transformers over
Includes the Service and/or Power Suppty up to 500 Amperes, All
Circuits and Two Inspectlon Trips Each Dwrelpng Unit @$80
(minimum total fee is $20)
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I hereby certlfy that I 6ispected the electrical ir�ta0atlon d�d�ed herafn on the datea sfeted:
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THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12
FOR OFFICE USE ONLY
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% [ You must cell the inspeaor when readyl Date Ready.
I certiiy that I am the LICENSED CONTRACTOR � COMPANY � OWNER and hereby request insp�tion of tt�e electrical work at
Job Slte Street Addr�s
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MaiUng Address (Co r, Com�ny or Owner Performing Irta�lledon)
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Autl�o SlgnaNre ntractor or Owner Pertorming Insfallatlon) Please Provida Two (2) Phorre Numbers Induding Area Code
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WSTRUC770NS ON BACK OF YELLOW COPY BOARD OF ELECTRICT' COPV Frimmm� e_�a a a�nne