P - 76210REQUEST FOR ELECTRICAL INSPECTION `" °=y �
2� 0���� 3 6 � Minnesota Btiard of Electricity
1821 University Avenue Suite 5-128, Saint Paul. Minnesota 55104
� (651) 642-0600 m/MRS 1-800-627-3529 www.electricity.state.mn.us '
pescribe -using th of the wh�e copy'rf necessary - the work covered by this request:
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ONE 8 TWO FAMILY DWELLIN�s, ta�n um i I � d
Includes the Service artdlor Pawer Supply up to 500 Amper�s, AA �\
Circuits and Tuw Inspection Trips Each DweUm9 Unit @$60
CIRCURS OF LESS THAN 50 VOLTS
�� YCK UIVI I
Per Unit
(minimum total f� is $20) ''
TF� AREN FOR PlSPECI0.3 USE OAA.Y
@$25 �1�+-e- ��lW" � �
HER ADDITIONAL FEES
�c .,e, r.,,r�� I herebY �Y �� Ns�tl the electrical mstallatlon dascribeE hereln on tlre dat
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�� Rough-In Ina�clion Requi�7 [�Yes ❑ No I�pection Other Then Rough-In: 0 Ready Now � WiU Cef�
��/�°� ( You must cell the inspector when readyl Date Ready:
I�rtify that I am the [�JCENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
! Job Site Street Address ��
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Sectlon Range Fire No. Counly
Township A � Q ��
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(CoMrac[or, Company or Owner Performing Installatlon)
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PY E&Q0001A-15 8.'1.2004