P - 77673REQUEST FOR ELECTRIC L I SPECTION
�" 6 41-111 �8 Minnesota Board of ElecUicity p{ ���� ���%�
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55 4
(651) 642-0800 TTY/MRS t-800-627-3529 www.electricity.state.mn.us
❑ NE ❑ REMODEL ❑ ADDITION REPAIR Describe -using the back of the white copy if necessary - the work covered this request:
�_S�c�f�( ��Y1'� OV019L ,S4n1/t E D J'i��
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or aratus $.50
ADDITIONS TO THE GENERAL FEES
3 to 12 Units @$50 Per
Each Additional Unit (� ;
Center
OTHER ADDITIONAL
Retrofit (� $.25 cer Fixture
BE
IIII II III II III II III II III II II) () III II III p� I�II
16411118
Traffic Signal Standard
Suoolemental Fee C� $
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes ihe Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
TOTAL FEE I
(minimum total fee is $20) �'�
iH15 AREA Fpi INSPECid21/5E ONLY
I hereby certify that I inspected the electrical installation described herein on the dates stafed:
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12 MONTHS _ �
Requesc vace: Rough�n Insp�tion Required? LJ Yes �I No Inspectiai Otlier Than Rough-In: �eady Now ❑ NNII Call
2z ��� ,.
—� You must call the inspector when ready! Date Ready:
I certify that I am the LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at: