P - 75689REQUEST FOR ELECTRICAL INSPECTION
�� o��� 112 � Minnesota Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 551 Q4
(651)642-08001TY/MRS 1-500-627-3529 www.electricity.stote.mn.us
Describe -using the back of the white copy'_rf necessary - the work covered by this request:
SUPPLIES
Above 200 Am ere a$10
ALARM, COMMUNICATION, REMOTE CONTROI
CIRCURS, CIRCUITS OF LESS THAN 50 VOLTS
Each Svstem Davice or Aooaratus (dD $.50
Each Addi�onal Unit @
OTHE
Liatitirm Retrofit (�a. $.25
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�071]1124
G@S
r Liuhtina Standard
overl0
ONE & TWO FAMILY DWELLINGS, EACH UNR
Includes the Service and/or Powrer Supply up to 500 Amperes, All
Circuits and Two Inspecbon Tdps Each DwelGng Unit @$80
Addfionallns 'onT' $20
Imrestlgative Fe.e
Reins 'on Fee $20
TOTALFEE
(minimum total fee is $20) ,�.� - S"'l7
nasa�aFai�usEaar
I hereW certlh� thet I ms� fhe electriml instellatlon d�d herefn on the detes s�ted:
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RE�}���A��Y 13 2007
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�� Rough-in Inspection Required7 ❑Yes �ldo Inspection OttrerThan Rough-In: ❑ Ready No�tl911fCell
�— Q You must call the inspector wfien readyl Date Ready.
I certidy that I am the �CENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request insp�on of the electrical work at
Job Site Street Address City
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Numbers Irtclt
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Cnntrador License Number Mas6er Electridan or F
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or Owner Perfortnmg Installadun)
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nnmer Performina Install� n) Please Provide Two (2) Phone Numbers
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