P - 78775REQUEST FOR ELECTRICA� IN�P�CTION
,,, �� J�— 7 0 3� Minnesota Board of Electricity -
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electriciry.state.mn.us
❑ NEW 0 REMODEL ❑ ADDITION REPAIR cnbe -using the back of the white copy if necessary - the work covered by this request:
f%f'e.�. ,L�.�.,,n�.o � �r�e��c�� s�'iCCJlC� ��QS%
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ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes ihe Service andlor Power Supply up to 500 Amperes, All
CirouiGs and Two InspecGon Trips Each Dwelling Unit � 38�
CIRCUITS OF LESS THAN 50 VOLTS
�ILY DWELLINGS PER UNI TOTAL FEE �2�` c'�Q
2 Units @ 850 Per unit (minimum total fee is $20) —� J
TMS FREA FOR WSPECTdt USE diY
Addi6onal Unit �$25 I hereby certity that I inspecoed nbed haein on �he d�es sl�d:
OTHER ADDITIONAL FEES ���
I(�II (I II� II �I� �I III II I� II I�I II I�I II�II �II) I IIN ,
L45o�o3� 30379
Nua-�i
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❑ OWNER and hereby request inspection of the electrical Mrork at: