P - 76048REQUEST FOR ELECTRICAL INSPECTION °'
1°�� 0� 4� 4� Minnesota Board of ElecVicity
1821 Universiiy Avenue Suite 5-128, Saint Paul, Minnesota 55104
r (651) 642-0800 TTY/MRS 1-800-627-3529 www.edectricity.state.mn.us
D�acdbe -using the bae�C of the white copy if nece�ry - the work covered by t�iis request: H c
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S1�Stem Device or A arah�s a$.50
ADDITIONS TO THE GENERAL I
MULTIfAMILY DWELLINGS (PER UNITI
Home Park Lots
� THIS INSTALLATION MAY BE ORDERED C
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18204347
Traffic Sianal Standard
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
CirariLS and Two Inspectlon Trips Each Dwe�ing Unit @$80
AddiGonal Ins 'on Tri $20
Investlgative F�
Reins n F� $20
TOTALFEE
(minimum total fee is $20) ,
TMSAflEA WPPBPECfdGUSEO�RY
I hareby certi(y U�at I inspected fhe electricai instaVatlan d� herein on fhe datea ata0ed:
FOR OF'FIGE USE ONIY
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12 MONTHS
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eq �1 nspectlon Otlter Than Rough-In: ❑ Ready PIow�Vill Call
�� •�� You muat call the inspedor when readyl Date Ready:
I certify that I am th@
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JSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
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ON BACK OF YELLOW COPY BOARD OF ELECTRICT' COPV FiL11M1111 A_15 a a�nne