P - 787901-4�71-152 �
NEW ❑ REMODEL ❑
CIRCUITS CIRCUITS OF LESS THAN 50 VOLTS
3 to 12 Units @$50 Per Unit
Exh Addi6onal Unit @ $z5
REQUEST FOR ELECTRICAL INSPECT�ON
Minnesota Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY�MRS 1-800-627-3529 www•electricity.state.mn.us
R Describe -using ihe back of the white copy if necessary - the work cs:�red bY t� request:
_. , %/� ._-� —^-�
-'�---------------------
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspec6on Trips Each Dwelling Unit @ 380
(minimum total fee is $20) I /IlL
TNlS MFA FOR INSPECT01tU5E 01-L�
I hereby cer6fy that I inspected the electrica� instaNation described he+ein on
Gi'�
1
Sta�A:
Inli
II III II III II I� h aI II IfI � IiI N lli n� l�
1471152? ��$�g Z�•��
Reques Dffie Rough-in Inspection Required? ❑ Yes No Inspection Other Than Rough-In: ❑Ready Now 0 VYII Call
�? �� You must call the inspector when reedy! Date Ready: .
I certify that I am ihe ❑ LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of tlie electrica� work at:
IN87RUGTON6 CN BACK OF VELLO�N COPr
BOARD OF ELECTRICITY COPV
EB-OOOD1M14 8.1.2002