P - 75913REQUEST FOR ELECTRICAL INSPECTION
I ���� I� 310 � M�� ��Board nue �S�S 28. SaiM Paut, Minrtesota 55104
� �� (651) 642-0��'I'�ARS 1-800-627-3529 www.electricity.state.mn.us
/
ALARM, COMMUNICATION, REMOTE CONTROL,
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
to 12 Units
Home Park
'ALLATIOId MAY BE ORDERE
Iul II ul II W II lu tI �� II ul II III I� IU �� I�
201731U0
I Transformers over 10 KVA $ 20
� Transfortner / Paaer Supply for Si / Outl'me Li Mmq $5
ONE & NVO FAMILY DWELLINGS, EACH UNIT
Im�udes tl�e Service and/or Power Supply up fi 500 Amperes, M
C'vcuits and Two Inspectlon Trips Each Dwelfing Unit (a� $80
Adrlitlonal Insneclion Trfis Ca� �20
TOTAL FEE I �� �
total fee is $20)
� hereby c�tl(Y that I 6�Cted Qre electrlcal inste0atlon desaibed f�erein on 9re detes s�ed:
i"OR OFFICE USE ONLY
���. !� r � �
� 1
�9 �
`� � � ` Rough-In Insp�don Requhed7 ❑ Y� ❑ No Inspec�on Other Tt� Ra�gh-In: eady Now �Wip Cap I
C You must cap the Inspector arhen readyl Date Ready:
I ceAify thffi I am the CENSED CONTRACtOR ❑ COMP ❑ OWNER and hereby request ins�tion of the electrical work at .:
,ion s�e saeec ad
°7�S � `-��� � c`� .��--.���'.�
c
� �
WSTRUCilON9
�-��ul-�i \
BOARD OF ELECTRICITY COPY
( ��r ° ��
�se Number Master Electridan or
cenae Number
Please Provide Two (2) Phone Number.
(�3 '��"%( S S
�7 [,/ I
FRJIIMNI�s1C o� ��w