P - 79187REQUEST FOR ELECTRICAL INSPECTION
�-� �� Q � C Q Q� Minnesota Board of Electricity
tJ � V J 1g21 University Avenue Suite S-128, Saint Paul, Minnesota 55104
� � (651)642- /MRS1-800-627-3529 www.electriciry.state.mn.us
❑ NEW 0 REMODEL ❑ ADDITION REPAIR Describe e back of the white copy if necessary - the work covered by this request:
�S1 /� �e C! � IvU�A �'`C"� � � . �- (.t�u( C P _
0
CIRCUIT
� 0 to
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or A aratus $.50
ADDITIONS TO THE GENERAL FEES
MULTIFAMILY DWELLINGS PER UNiT
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
Traffic
Fee $20
ao to 10 KVA
� Transfortner / Power SuDPIy for Si9ns I Outline Ligh6ng @$5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Senice andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Umt @$60
(minimum total fee is $20) I 4�d `
THIS AREA FOR IISPECiOR USE IXAY
I hereby ceNry tl+at I inspecc�d th� elec0ical instaNaSon described herein on the dates stated:
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Request Date: Rough-in Inspection Required? ❑ Yes No Inspection Oth� Than RougMn: eady Now ❑ Vlhtl Cell
S-()-{(� You must call the inspector when ready! Date Ready:
I cerfiy ttiat I am tl�e �j LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby �equest inspection of tt�e elecfical work at::
x
Job Site Address (Street, Box, w Route No.) iN Zio Code
N/A
{ Uc�,se Mumber
KOVAR ELECTRIC LLC CA03644 �
ling Address (Contractor, Company or Owner Performing InsWllation)
23049 ARROWHEAD ST NW SI' FRANCIS MN 55070
horized S' ure (CoMractor, Company or Owner � rming Installation) Phone (s)
163-753-5731
IRUCTONSOI/BAC%OFYE COPY BOARDOFELECTRICITYCOPY EB-00001M71 8.1.2002