P - 786011 REQUEST FOR ELECTRICAL INSPECTION � �
�1. � 3 9�J � J o v � Minnesota Board of Electricity °- .:
`,^,/ 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
�/ /LJn (651) 642-0800 TlY/MRS 1-800-627-3529 www.electriciry.state.mn.us
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0 NEW ODEL 0 ADDITION REPAIR Describe -using the back of the white copy if necessary - the work covered by this request:
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GENERAL FEES Outdoor Lighting Standard �$1 _
401to
ALARM,
CIRCUITS OF LESS THAN 50 VOLTS
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Indudes ihe Service andlor Power Supply up to 500 Amperes, All
Cirouits and Two InspecGon Trips Each Dwelling Unit �$80
3 to 12 Units @$50 Per Unit (minimum total fee is $20) J�C/
E2Ch Addition2l U�ii � $25 TwsnnEnFOairavECroausEaar
, I hereby ce�Efy that I inspec[ed the electrical i�tallation dexribed herein on the d�es sta�d:
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I III) II II� II III I� III II III (I (II ��I � III �� I�� 1
1 3 9 9 9 0 8 1 '��` ��
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Request Date: Rough-in Inspection Required7 ❑ Yes gRo Inspection Olher Than Rough-In: ❑Ready Now I Call
�1�� � You must call the inspectar when ready! Date Ready:
i certify that I am the �CICENSED CONTRHCTOR �COA�IPANY ❑ OWNER and hereby req�st �spection of the elecUical wak at: