P - 78856REQUEST FOR ELECTRICAL INSPECTION
1�"r V f' - 2 6 7 9❑ Minnesota Board of Electricity
18 University Avenue Suite S-128, Saint Paul, Minnesota 55104
� 2-0800 TTY/MRS 1-800-627-352g www.electriciry.state.mn.us
NEW ❑ REMODEL ❑ ADDITION 0 R IR cribe -using the back of the white copy if necessary - the work covered by this request:
�� i: �n �
o to
3to12
�MMUNICATION, REMOTE CONTRO!
CIRCUITS OF LESS THAN 50 VOLTS
$50
I illl il Iii II III I! NI il III II III il III II In �� I�.
14672679
0
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, AII
Circuits and Two Inspection Trips Each Dwelling Unit �$80
TOTALFEE
_ (minimum total fee is $20) p� Q
r�ns a�n von uuaECroa usE orcr
I herebY certify that I inspec(ed the electrical inspYaCpn desaibed herein on tlie da�s slaled:
�
�nnECrED IF NOT COMPLETED WITHII
a�5
� 3 ��a
Rough�n Inspection Required? ❑ Yes No �r�speUip� p�her Than Rough-In: Ready Now ❑ yNll Call
� � 3 Vou must call the inspector when ready� Date Read
Y
I certfy�that I am the �LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request ins
pection of the electrical work at::
EB-00001A-14 8.1.2002