P - 75804i REQUEST FOR ELECTRICAL INSPECTION
1��3 �, � 17 2� Minnesota Board of Electricity
1821 University Avenue Sutte S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-8Q0-627-3529 www.edectriciry.state.mn.us
� Descn'be -using the tr�ckbf efi�'te copy'rf naassary - the wo�C coverai by th� r�ue.st:
I I SERVICES /
CIRCURS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Ap �aratus @$.50
ADDRIONS TO THE GENERAL I
MULTIFAMILY DWELLINGS PER UNI
3 to 12 Units @$50 Per Unft
Each Additional Unit (�a $25
Center
THIS IMSTALLATION MAY BE ORDERED
(II� UIII IIUI �UI Ulu UIII II� IIUI �� I�
19371723
� Transformer 1 Power SuPPIY � Siqns / Outline Li hti Q$5
ONE � TWO FAMILY DWELLINGS, EACH UNIT
Indudes the Service and/or Power Supply up to 5D0 Amperes, All
Circuits arM Two Inspection Trips Each Dwe�ing Unit @$80
Add�ional Inspectlon Trips @ $20
Investipative Fee
total fee is
I hereby certity that I inspeded the electrhal NstaOadun desaibed herem on fhe dates staled: �
IR NOT COMPLETED WITHIN
FOR (�FFiC[ US�+'JNLY
� �. "l,t G —o t
1O' ` Rough-InlnspedionRequired? ❑Yes ❑No I�pectlonOtherThanRough-In: eadyNowOWillCell
�/���� You must call the inspedor when ready! Date Ready.
I certify that I em the UCEWSED CDNTRACTOR ❑ COMPANY ❑ OWNER and hereby r�uest insp�tion of the electrical work at
I Job Site Sh�t AddreSS .� , �n„ �, , r
DEPERlDABLE
numoraea �� mtacror or ofm
WSTRUCTIONS ON BACK OF � LO COPY
��C•
�
BOARD OF
� �� ° �o����')
� Number Mester �ectridan or Power Limited'
�i��K� Ucense Number /�_�{///fy[d
� • �i
r
�lease Provide T� (�Pho�re Numbers Inciuding Area
�" �' °°° .� ,��
ca_nnrm�n �c