P - 75881REQUEST FOR ELECTRICAL INSPECTION � '
�� 9��� 4 4 7� Minnesota Board of EI 'city
1821 University Avenue S' e aint Paul, Minnesota 55104
(651) 642-0500 TTY/M 1��7- 29 www.edectvicity.state.mn.us `'
Destxibe -using the back of the e copy If n� - the w�Yic covered by tf�is uest:
0 to 200 Am ere �$5
Above 200 Am re $10
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
3 to 12 Units (iD. $50 Per Unit
Manufactured Home Park
Recreational Vehicle Park
THIS iNSTALLATION MAY BE ORDERED
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19964477
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Ir�cludes the Service andlor Power Supply up to 500 Amper�s, All
Circuits and Two Inspection Trips Each Dwelling Unit @$BO
Addi�onal Insaeclion Trias (�a. $20
total fee is
I herebY certlN that I insPeded the alectrical insiallatlon desa�ed h�ein on the defes s�:
FvR �iFFICE USE CNVIY
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�� Rough-in Inspectlon Required7 ❑Yes ❑ No I�pectlon Ofher Than Rough-In• Ready Naw �Wpl Cap
�� �`�C/�` You must cali the inspectar when readyl Date Ready.
I certify that I am the �ICENSED CONTRACTOR ❑ COMPANY ❑ aWNER a� hereby request inspecb� the ele� trical work at
Job Site Street Add _ . , , _ C' _ ` ,n
CompanyName
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ise Number Mavter Electri or Power Limlted echni
� �L(cense Num isy l
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Please Provide Two (2) Phone Numbera indudtr�g Area Code
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