P - 79096REQUEST FOR ELECTRICAL INSPECTION '
1�' 6 g�-� 0 3 7 � Minnesota Board of Electricity -
1821 University Avenue Suite S-128, Saint Paul, Mi�nesota 55104
° - � (651) 642-0800 TTY/MRS 1-800-627-3529 wiv+v.electricity.state.mn.us
0 NEW ❑ REMODEL 0 ADDITION REPAIR„ Descdbe -using ihe back�f the whi� copy if necessary - the work covered by ihis request:
!�/c,� �1 ree�t�rc � d S�'R.'!�<� -e d- �'ea�� ��.5 t� f�G ��-
to 400
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Fee
Includes ihe Senice andlor Power Supply up to 500 Amperes, All
Grcuits and Two Inspecdon Trips Exh Dwelling Unit @$80
nrnm��� UY\CLLIIVUJ rCRV1Y11 �v�n�rc� L,/
3 to 12 Units �,1$50 Per Unit (minimum tOtal fee is $20) �/ I�L:�
E2Ch AddiliOnal Unit Q$25 T�asu�,Fa+i�cToaus�aav
I hereby cerGfy Uwt I i�spec0ed the ekctrical instaN�on described herein on tl�e daAes sfafed:
OTHER ADDITI ONAL FEES •? Q � (/ ^ �; � � � �
Liahfina Retrofit � 8.25 oer Fixture �` r
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Request Dete: Rough-in �nspedion ReQUired7 Yes No Inspeclion Otlier'Ih� Rough-In: OReady CaN
�� � i' Q� You must eall the inspecfa when readyl pe(e R�y;
I certiry ihat I am the �CENSED CONTRACTOR ❑ C�ANY ❑ OYVWER and he�eby ►equest inspection of ttie electrical wark at:
Job ' Addness (Street, Box. a Route No.) ZiD Code
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