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P - 76163REQUEST FOR ELECTRICAL INSPECTION ' �� 0 6���F � 9 � Minnesota Board of Electricity 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 � (651) 642-0800 TTY/MRS 1-800-627-3529 www.edectricity.state.mn.us Describe -using � back of the ite copy ff nec�ary - the ork covered b requesst: l/l%�,� � /s ur /� 4� �- /' o� 1MMUNICATION, REMOTE CONTROL CIRCUITS OF LESS THAN 50 VOLTS CC] 5 per F6diue Boom C� $4( Mile I�I (� lu u��I I� �II II I�� II II� u I�I II III �� I� 20�74891 Fee ONE 8 TWO FAMILY DWELLINGS, EACH UNIT Includes the Service and/or Power Suppiy up to 500 Am�res, All CircuiG4 and Two Inspecfion Trips Each Dwel�r�g Unit @$80 Addfional Ins on Trf $20 Inv�stigative Fee Reins on Fee $20 TOTAL FEE (minimum total fee is $20) THIS AREA FOR PSPECiOR I1SE OM.Y I hereby cerdry tlmt I inspeded the electrlcal installadon d�atbed herein on fhe daaes s�ted: FOfi UFFtGE USE ONLY � ���a �� 3. :: Rough-in InspecHon Required? ❑Yes��iVo Inspeclion OtherTh� ��eady Now �WIA Ce8 You must call the inspector when readyl Date Ready. I certify that I am the LICENSED COPITRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of th� electrical work at or s A< _, �� -�7 - ������ --' Liwr�se Numbe� Mester Electridan or P C(./ uaer�se Plumber i� � PIe��Provl e �i2) P�u � �u 1PV