P - 78878c c REQUEST FOR ELECTRICAL INSPECTION
1� U�� V- 4 9 2� Minnesota Board of Electricity -
r 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
+ (651) 642-0800 TTY/MRS 1-800-627-3529 www.electricirystate.mn.us
❑ NEW ❑ REMO ❑ AD�I ON ❑ REPAIR Describe`uling the hqck of the white copy if necessary - the work covered by this request:
401 to
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
! CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
3 to 12
Each A
Fee
0
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit �$80
��^ �"" TOTAL FEE ��
Unit (minimum total fee is $20)
i25 Tws ut�r, Fa+ws�ctart use aar
I hereby cerAry Mat I inspected the ekctric� insWl�on desxibed I�erein on tlie da6es staled:
:ADDITIONALFEES ��Q u� �/,J3 (
�er FiMure [ `� �
_ . . .. . _ _ __ -_ _-_ _'_��""��' �� .. ..... ..v.... �.� � �u ��� � nn� �L mVR 11'1J
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16664922
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�� �e� Rough-in Inspection Required? ❑ Yes ❑ No Inspedion Other Than Rough-In: ady Now 0 VNII Call
You must call the inspector wF�en ready! Date Ready:
� certify that I am �e ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electriql work at:
Jotl�Site Address (Street, Box, or Route No.) C' Zip Code
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INBTRUC710N8 ON BACK OF YELLpW C BOqRp pF ELECTRICITV COPY
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+q (2) /Pjhone Nfum Induding Area CoCe
/ ✓' ��.7/ /
Master decfician or Power Limited T ician
�
License Number�
(s)
> - 7s_
EB-00001M14 8.1.2002