P - 78783REQUEST FOR ELECTRICAL INSPECTION
1� 4� 7� 3 7 2 3� Minnesota Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
,. i��� (651) 642-OSOO TT'l�MRS 1-800-627-3529 www•electricity.state.mn.us
r, .����� �` RFMODEL ❑ ADDITION ❑ REPAIR Describe -using the back of the whit \ opY if necessary - t'e �� �� by this request:
HIJIRIYI� vv�..�......._.... _
CIRCUITS, CIRCUITS OF I.ESS THAN 50 VOLT
3 to 12 Units �$50 Per Unit
Fx.h AddiGonal Unit @ 825
I II�� II III II II� �I N� II III II I�I II II� II III �� I�
1 4 8 7 3 7 2 3
ONE & TWO FAMILY DWtLLIrv�a, v+�� ���" �ps, All
Includes the Service andlor Power Supply up to 500 Ampe
Circuits and Two Inspection Tnps Each Dwelling Unit �$�
TOTAL FEE I .�� � Q
(minimum total fee is $20) �'`
TMS �� Fpt iNSPECTOR USE OPLY n on tlie dates sfaled
I hereby cerMY that I inspected the electrical instaNation descnbed herw
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�� p�e; Roughin Inspettfon Required? ❑ Yes o Inspedion Other Than Rough-In: �Ready Now
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�� 1(� � �� You must call the inspector when ready! Date R�dy. .
� certify that I am the �ICENSED CONTRACTOR ❑COMPANY ❑ OWNER and hereby request inspecti �of ihe electrica�'N°rk at:
�� �- - � EB-OOOU1A-14 8.7.2002
INS7RUC" �ONS ON BACK OF YELLOW COPY BOARD OF ELEClWCT' COPY