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P - 76356�}��� `� REQUEST FOR ELECTRICAL INSPECTION ✓ �� J�� � 0�°� 1 2 � Minnesota Board of Electricity 1821 University Avenue Sufte 5128, Saint Paul, Minnesota 55104 (651) 642-OS00 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us Desaibe -using the back of the white copy ff na�ssary - the a�ork cover� by this r�u�t: �(�c� i nn ��i r���.n o� V�D n i�-cr Qn �-- �� �=�:• I SERVICES / �e eoo �UITS / FEE 0 to 200 Ai F� � over A6ove 200 Am re 10 Includes the Service andlor Power Supply up to 500 Amperes, AII tM, COMMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Two Inspection Trips Each DwePng Unit @$80 ;UITS, CIRCUITS OF LESS THAN 50 VOLTS Add'fional Ir�s 'on Tri $20 Each S em Device or A paratus (a� $.50 Invesd ative Fee ADDITIONS TO THE GENERAL FEES Reins on Fee $20 TIFAMILY DWELLINGS PER UN TOTAL FEE /�'� � 3 to 12 Units @$50 Per unit (minimum total fee is $201 l i Home Park Lots l Vehicle Park Sit�s INSTALLATION MAY BE ORDERED I i�eded tlre etectrical i�aVaUOn desamed herein on the da0as st�d: � anre�1 /v� ea_5.v.e..�. '��...�-_?r:� O `'/ o ' FpR O�FICE USE OtyLY INIIIIIII��II�IIi�lillllll�llllllll��l� ���- ��� 182D2721 3 � ( � c�� �' Rou h-in I� n R uiredl ❑ Yea ❑ No Ins g pectlo eq pedion OUiiar Than Rough-In�Ready Now ❑ WN Catl �— f�� �� You must cell the inspec4or when readyl Date Ready: 3—' q-���� "I certify that I am the 0 LICENSED CONTRACTOR ❑ COMPANY �OWNER and hereby request inspection of the el�trical work at Job Sfte Street Address �hy S�73 �i r+hur S� �l1 � �r°► d l ev ��CQ, or � � ���������� master tiecmctan or Licer�se Number Including u.�° �tQ/w - b / / �b/ � � v ON BACK OF YELLOW COPV BOAR�f ()F FI Ff:TRIf:T' f:f1PV ca_rxinn� e_na e