P - 76255� � � � � � � , I�QUEST FOR ELECTRICAL INSPECTION
a � � Minnesota Board of Electricity
1821 University Avenue Suite S-128, SaiM Paul, Minnesota 55104
. .(651) 642-0800 TTY/MRS 1-800-627-3529 www.edectricity.state.mn.us
Des�rt�9 �usim� �e back pf the white copy'rf nec�ssary - the vrork coveral by this request:
SERVICES / POWER SUPPLIES
� Above 200 Ampere �$10 �
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCURS, CIRCURS OF LESS THAN 50 VOLTS
Each Addfional Unit �
Retraflt
I II�I (� III u W�� lu II III II III II I�I O ul �� I�
21202�98
Fee
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits arid Two InspecUon Trips Each Dwellrmy Unit @$80
Addi�onal Ins 'on Tri $20
Investi ative Fee
Reir�s on Fee $20
TOTALFEE •
(minimum total fee is $20)
ZI� ,�,�,����Y
.,� �d e
I hereby cazd(yNaf I 6ispeded the electrical I�Oetlon descn'bed hereln on fFre datea steted:
�� �. 3 �,�
�� � � � �-a�
;: /7 .— O
FOR OffICE USE ONLY
RECD MAR 3 0 2007 �pd'� C�pc��
��-2%—�% RouBh-in Irrepectlan Requhedl Q(Yes ❑ No Inspedlon Other Then Rough-In: � Ready Now [�INm Ca0
You must ca0 tha inspector when ready! Date Ready.
I cerbfy that I am the�7 UCENSED COPITRACTOR ❑ CO�IPANY ❑ OWNER and hereby request insp�iion of the electrical work at