P - 759081 9 9 a �5 �� REQUEST FOR ELECTRICAL INSPECTION
� � � Minnesota Board of Electricity
1821 University Avenue Suite 5-128, SaiM Paul, Minnesota 55104
_�� l�Ct'�-.� (651)642-OSOOTTY/MRS1-800-627-3529www.electricity.state.mn.vs
Desaibe -using the bay� of� th�e white coPY ff ���Y - the xro k covered by this request:
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I SERVICES /
IALARM, COMMUNICATION, REMOTE CONTROL
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each Additlonal Unit @ $25
OTHER ADDRI01
Linhtirta Retrofit C� $25 aer Flxture
Includes the Service andlor Power Supply up to 500 Amperas, An
Circuits and Tvro Ins�ction Trips Each Dwellir�g Unft (a� $80
TOTALFEE
total fee is $20)
I hreoected the electrical InafaDatlun d�d h�ein on the datea stet�:
p�-- 7 �U— C_'✓� �
�ection @$.31 per Mae I I
1LLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
FOR OFPICE USE ONLY
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��t� Rough-in Inspectlon Requiredl ❑ Yea o Inspedlon Other Than Rough-In: 0 Ready Now Ce�
`� ��� '�,7� You must caU the inspector when readyl Date Ready:
I certify ttiat 1 am the �LJCENSm CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request ins�tion of the electrical arork at
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Electrical Uiil�y Address
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