P - 75686REQUEST FOR ELECTRICAL INSPECTION
�— �. 6�-� 117 � Minnesota Board of Electricity
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.zcr
D�cnbe -using the back of the white co�y ff ne�ssary - the vrork covered by this request:
Above 800
;URS / FEI
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
3to12
dNional Unit @
OTHE
Retrofit (m $.2;
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II� II �I N�I d Ili II III il �I il III II I� �� i�
�07[71173
Traffic
Includ� the Service andlor Power Supply up to 500 Am�res, M
Circuits and Two InspecUon Trips Each Dwaliing Unit (o� $80
Add(tlonal Ins 'on Tri $ZO
Imesti ative fee
Reins 'on Fee $2(1
TOTALFEE
(minimum total fee is $20) g
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I frereby certliythet I inspeded the electrfcal iretellatlon desaibed hereln on fhe dates s�ted:
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FOR GF�tr'E USE ONLY
REC'D AU G 13 2007
o�Ob� �/�a-
�� Rough-in Inspecdon Required? ❑ Yes �}No Inspectlon Other Then Rough-In: � Ready Now.8V7N Cell
� You must ca0 the inspector when readyl Date Ready:
I cerMy tl�at I am the � LICEfdSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request insp�tion of the electrical work at
Job Site Street Address Cfty
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ise Num6er Master dectridan or P
License Numher
, Gompany or Ovmer Perfortning Installedon)
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itrador or Owner Perfortning I on) Please Provide Twa
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