P - 78693°' REQUEST FOR ELECTRICAL INSPECTION
�� - 4 3 0-17 4�1 Minnesota Board of Electricity -
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
�f����/,�� (651)642-0800TTY/MRS 1-800-627-3529 www.electricity.state.mn.us�,
❑ NEW EMODEL ❑ ADDITION ❑ REPAIR Describe -using the back of the white copy if necessary - the work covered by this request:
l�Y� C�Li,�J�`Y1 �u5%�'%%7—'%5 .
o to aoo
CIRCUITS, CIRCUITS OF LESS THAN 50 VOL
Mile
�Y BE
IIN �I III II III II ill II 10 II III II III II III � VI I I�
1,4301741
Transformers u to 10 KVA $10
Transformers over 10 KVA $ 20
Transfortner I Power Su I for Si ns I Outline Li htin 35
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes ihe Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit �$60
Addi6onal Ins tion Tri $20
Investi ative Fee
Reins tion Fee $20
TOTALFEE
(minimum total fee is $20) � �
Twsnnucortxa�ctat orar
I he2by certify that I inspecEed the ekctrital insWlation described herein on tl�e da0es stated:
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Reqt�st Date: Rough-in Inspecfion Required? ❑ Yes No Irupection Other Than Rough-In: ❑Ready Now Will Call
��3� You must call the inspedor when ready! � Date Ready. .
I cerfity ihat I am ttie?�LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspec�on of tl�e electr�al wak at:
INS7RUC' ANS ON BACK OF YELLOW COPY BOARD OF ELECIRICT' CAPV EB-0OOO7M14 &1. 2002