P - 785831-�0$=779 �
r❑ NEW ❑ REMODEL ❑ ADDI71oN �+sl Ker
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,UITS, CIRCUITS OF LESS THAN 50 VOLTS
Each Svstem Device or Apparatus �$.50
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
REQUEST FOR ELECTRICAL INSPECTION
Minnesota Board of Electricity
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www•electriciry.state.mn.us
R Describe -using the back of the white cop sary - the work covered by this request:
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ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Cirouits and Tvro Inspection Trips Each Dwelling Unit �$�1
Additional Inspection Trips S20
Investiaa6ve Fee
-- - —
TOTALFEE $'D
(minimum total fee is $20) i ��
T HIS MEA FOR N15PECTd2 tAE ONLY
1 hereby cerM1fy mat I inspected the eleclrical i�talW6on described herein on the dales sf�ed:
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a -im ms -um� �v.� � �, �•,��••
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WIT _�__ _
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L4U8779 5 ,5"
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Request Date: Rough-+n Inspection Required? ❑ Yes Inspedi Other Than Rough-In: Ready Now � Nk� Ca��
���'7 � � 3 You must call the inspector when ready! Date Ready. .
I cefi(y ihat I am the �.LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the elecfical work at:
�ry Zip Code
Job Site Address (Street, Box, w Route No.)
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ower Supp�ier
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onVactor / Company Name
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lailing Address (Contractor, Company a C
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INBTRUGTIONS CM
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Contrador License Number Master ElecVician or Power umnea � wn� ����a �
� /7 (% / 7 � / License Number
ier Perrortning Nsfananon>
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• pwner Perfortning Install ' ) Phone (s)
763 -�sd -(oa/°
BOARD OF ELECTRICIN CAPV EB-0OOOtA-14 8.1. 2002