P - 75834REQUEST FOR ELECTRICAL INSPECTION
1 B� 2�_ q, � g� Minnesota Board of Electricity
1821 University Avenue SuRe S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.edectricity.state.mrz.us
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Describe -ustng the backs�fthe white copy if necessary - the xrork vered by thislrequ�st: 4•�y �R, �
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UITS, CIRCURS OF LESS THAN 50 VOLTS
Each Svstem Device or Aaparatus id $.50
Cerdet
Includes the Service arid/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Eash Dwelling Unit @$80
Addfionallns 'onT' $20
Investigative Fee
Rems n Fee $20
TOTAL FEE o Ly�
(minimum total fee is $20) J�
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I hereby certlfy Net I inspected the electrlwl Insfs0a8on desamed irerein on the dates stated:
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� Special Insp�Uon �$.31 per Mile I I
THIS IPISTALLATION AAAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MOIdTHS
FOR QFFICE USE ONi'r
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18204693
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�' Rough-in Insp�lion R�uUed9 ❑ Yes ❑ No Inspectlon Ofher Than Rough-In: ❑ Ready Now�(Hm Cell
� You must cell the inspector when readyl Date Ready.
I certify I am the � LICENSED CONTRACTOR � COMPANY ❑ OWNER and hereby request inspection of the electrical work at