P - 75692REQUEST FOR ELECTRICAL INSPECTION
� � Minnesota Board of Electricity
2 �� �.14 �
1821 University Avenue Suite 5-128, Saint Paul, Minnasota 55104 -'
(651)642-08001TY/MRS1-800-627-3529www.electvicity.state.mn.res ' °�
Describe -using the back of the white copy'rf nec�.sary - the owrk covered by this request:
GENERAL
Above 200 Am ere $10
ALARM, CAMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCURS, CIRCURS OF L�SS THAN 50 VOLTS
Each Additlonal Un(t @
I ��f^:
I uu 0 UI II W� I�� II I�I II III u II� II III �� I�
?a�r�1�4o
F]'�iTF?i�l
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Pawer Supply up to 500 Amperes, All
Ciraiits and Twro Inspectlon Trips Each DwelGng Unit @$80
Additional Insa�tion Trfas Cc� $20
total fee is
I Nspeded the electrical instellatlon desatbed herehi on the dates sfa�:
�r'
F�7R Ok'FICE USE OPdIY
�� �uG 1 � 200�
�� �` � �
�� Rough-in Inspectlon RequUed7 ❑Yes � Inspealon Otlier Than Rough-In: ❑ Ready No�Cell
-� D 7 You must call the Nspector when readyl Da[e Ready.
I certify that I am the ❑ LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER ami hereby tequ�t mspection of the electrical work at
I/T�.+� �
Please Provide Two (Z) Phone Numbers Irtc
\ / \ /
neesmr Frecatc�an or
Licenae Nwnber
�/'� ,/ . .,; — /