P - 75735�-` REQUEST FOR ELECTRICAL INSPECTION
��� J�- 5 010 Minnesota Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651)642-0800TfY/MRS 1-800-627-3529 www.edectricity.state.mn.us
Describe -using the back of the white copy'rf necessary - the amrk cxivered by this requ�t: ����
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o�l.�ua o,► 1 a,a l�. �'� G3<<fJ
/ POWER SUPPLIES
� CIRCURS, CIRCUITS OF LESS THAN 50 VOLTS
Each Svstem Device or Aooaratus C� $.50
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
Retrofit
�er Hour
r M�e
RfIAY BE ORDERED
I��I �I II� II III II 0I II (II II I� II lu � W� W I�
18965�1�
Fee
ONE & T�NO FAMILY DWELLINGS, EACH UNR
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuils and Two Inspection Trips Each Dwelling Unit @$80
Fee
i v uu. rr.t , t 10 � J O
nirnmum total fee is $20)
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I hereby ceAify Umt I
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fhe elec�ical mstaVatlnn desrnbed herdin 6n tlre � sTated:
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VIPLETED WITHIN 12 MONTHS
^Cj{i,cp'�,._U7EC�f�:. � �°C�j� e/
�� Rough-in Inspecdon R�uUed7 �s ❑ No Inspection Other Than Rough-In: �ryteady Now ❑ WN CeG
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You must call the inspedor when readyl Date Ready:
I cerMy that I am the �ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspec.fion of the electrical work at