P - 78959R T REQUEST FOR ELECTRICAL INSPECTION
1� U� V- 2 2 3❑1 Minnesota Board of Electricity -
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
��(_.�f r"1 (651) 642-0800 TTYIMRS 1-800-627-3529 www.electricitystate.mn.us
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❑ NEW EM DEL ❑ ADDITION ❑ REPAIR Describe -using the back of the white copy if necessary - the work covered by this request:
�b ����� �-, l.Ps l - "1-t � - �l� $�
UITS, CIRCUITS OF LESS THAN 50 VOLTS
Each Svstem Device or Apparatus @$.50
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
Pivot Irtiaaation Boom
Mile
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$BO
TOTAL FEE I �
(minimum total fee is $20) p�
iH15 MEA FOR INSPECiOR lAE Q1Y
I herebY cer9fy Mat I inspected the eVecgical instaN�on described herein on the daffis st�d:
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R uest Dffie: Rough-in Inspection Required? ❑ Yes Inspection Other'fhan Raugh-In: ❑Ready Now NAII Call
�- a•� You must ca�l the inspector when ready! Date R�dy:
I certify that I am tl�e �ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of tlie electrical work at:
Job Site Address IStreet Box. w Roule No.l CiN Zie Cede
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F9�OO�UtMiI 8.1. 2002