P - 78692/� /� REQU�ST FOR ELECTRICAL INSPECTION
���}��F 0- 4 21 � Minnesota Board of Electricity -
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(/�(,�z ' (651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
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❑ NEW $REMODEnL ❑ ADDITION ❑ REPAIR�I Describe -using the back of the white copy if necessary - the work covered by this request:
/ ( i� �//'i /J4�:%'1 b�/.— / / % � 7�S _ _
GENERAL
401 to
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each Svstem Device or Appazatus �$.50
�50 Per Unit
Unit � $25
i Ilii II (i� II il� II lil il III il III II Il) II II� a�l I i�l
1 4 4 0 4 2 1 4
Standard
20
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 �$60
TOTAL FEE I ��,�,�
(minimum tohal fee is $20)
Tws u�a Fa+�cTaa usE aar
I hereby ceAify thffi I inspected the elecbical installa6on described here� on Ihe daBes sta6ed:
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ReQ� �� Roughin Inspection R�equired? ❑ Yes �'No Inspection Other Than Rough-In: ❑Ready Now�Mlill Cdl
�� /6 �3 You must call the inspector when ready! Date Ready:
1 certify that I am the �B'UCENSED CONTRACTOR ❑COMPANY ❑ OWNER and hereby request inspection � tlie electrical wak at: