P - 77002✓ � _
� 1 Z 9 3 Z 3 � REQUEST FOR ELECTRICAL INSPECTION
� � Minnesota Board of Electricity
�� 1821 University Avenue Suite S-128, Saint Paui, Minnesota 55104
��� (651� 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.
Desaibe -using the back of the white copy'rf necessary - the work covered by this request:
�r�b C� o�� �So,n �ra S \' "l-1 '1--1 �$s
0 to 400
CIRCUITS OF LESS THAN 50 VOLTS
>vstem Device or Aoparatus � $.50
I MULTIFAMILY
Center Pivot Irrigatio� Boom
Manufactured Home Park Lc
Recxeatanal Vehide Park Si
LATION MAY BE ORDERED [
i�IN�����I�IIIiIa��Ul��l�l�
21293238
ONE 8 TWO FAMILY DWELLIN�S, EACH UNfT
Includes the Service andlor Power Supply up to 500 Amperes, All
CircuiGs and Two Inspection Trips Each Dwelling Unit �$80
Additional Ins ion Tri 320
Investi tive Fee
Reins ion Fee $20
TOTALFEE
(minimum total fee is $20) �
rws uten Fae miscECroa use awir
I herebY certiry ihal I inspeded the electrical insf�latron described herein on the dates stated:
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You must call the inspector when ready! Date R�dy:
I ceMify that I am the ICENSED CONTRACTOR ❑ COMPANY ❑ OWNE12 and hereby request inspection of the electrical work at
Job Site Street Address �' �
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Towmship Section Range Fire No. Cou ty
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Owner pant Name Please Provide T`wo ( Phone Numbers Including Area Code
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Elechical Utility Electrical Utllity Address
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��(� � �r1('Z ` License Number
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