P - 78666REQUEST FOR ELECTRICAL INSPECTION
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1� 4 0 0— 9 8 4�9 Minnesota Board of Electricity : ;'
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
� (651) 642-0800 TTY�MRS 1-800-627-3529 w�+'w•e[ectricity.state.mn.us
EW ❑ REMODEL ❑ ADDITION EPAIR Describe -using the back of the white copy'rf necessary - the work covered by this request:
_ i 1. � _ . _ . � � 2 /� /� %v /DO� /� c%'-4 �—i !f
n e,.,ro�e � $5 .St X 1 '�
�!I(1 Amc�ere �$10
iMMUNICATION, REMOTE CONTROL
CIRCUITS OF LESS THAN 50 VOLTS
to 12 Units �$50 Per Uni
nch AAAitional UNf � $25
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and�or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit � b80
TOTAI fEE -3�—
(minimum total fee is $20) �� —
THIS ANEA Fqt UEPELTOR USE p4Y
I hereby certiry that I inspected the electrical ir��b°n deuribed herein on tlie daRes sta�ed:
—'� ` G
S ial Ins tion $.31 r Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MO
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� n Other Than Rough-In: ❑Ready Now VY� ��
{Z��� � Rough-in Inspeclion Required. ❑ Yes No I^Specti°
Vou must call the i�speda wh� readY! Date Ready: .
I certify tl�at I am ttie �LLICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and he�eby ►equest inspectioo of the electrica� wor� ��
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gpqRp OF ELECTRICITV CAPV
Master pflCtripan a
License Number ,�
Z38-6S6Z I
E&00007A•74 8.1.2002