P - 79161REQUEST FOR ELECTRICAL INSPECTION
��� J�- � 6 5 0 Minnesota Board of Electricity -
1821 University Avenue Suite 5-126, Saint Paul, Minnesota 55104
� (651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
❑ NEW ❑ REMODEL O ADD�N ❑ REPAIR Describe -u� the back of the white copy if necessary - the work covered by this request:
0
800
�UITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENERAL FEES
fIFAMILY DWELLINGS (PER UNIT)
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelting Unit �$80
Reins tion Fee $20
TOTAL FEE
(minimum total fee is $20) �
THIS ARFA FOR IfbPECiqi USE ONLY
I hereby certify that I inspected the electrical installa6on described herein on the dales sta6ed:
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Raq�st Data: Rough-in Inspection Required? ❑ Yes No Inspedion Other Than Rargh-In: Ready Now � VYNI Call
IZ- IQ-43 You must call the inspecta when ready! Date Ready.
I certiy that I am the � LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electripl work at::
I.1ob Site Address (Stree� Box, ar Route No.l Citv ��� r.,n.
I 94
BoB wtcx�r -
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ConVactor / Company Name
KOVAR ELECTRIC LLC
Mailing Address (Contracta� Company or Owner Porform
23049 ARROWHEAD ST NW ST
7 A r�ease Proviae rwo �
�� 66�-�sa-aaoo
er Address
X
CA03644
MN 55070
masrer r�ecmcian or
Lic�se Number
� -����,,,'�_� I 763-753-5731
IN87RUGTONS ON BAGK OF YELLOW COPY BOARD OF ELECTRICITV COPV EB-OOOOtA-71 8.7. 2002