P - 787161— 4 O 5�`'` 4 2 9 � REQUEST FOR ELECTRICAL INSPECTION
� Minnesota Board of Electricity
X I� O�� 1821 University Avenue Suite S-128, SaiM Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800�27-3529 www.electricity.state.mn.us
NEW ❑ REMODEL ❑ ADDITION O R�PAIR �BRSCribe -using thepxk of ihe white copy 'rf necessary - the work covered by this request:
0 to 400
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS _
S50 Per unit
Unit � S25
Fixture
CeMer
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Indudes Ihe Service andlor Power SuPpIY up to 500 Amp�es, All
Cireuits and Txro Inspectlon Trips Each Dweiling Unil � S80
(minimum total fee is SZO) ��J .JV
TM5 AREA FOR Il6PECTOR USE pLY
� hwepy eetify that I irepecled Meekctrical ir�fall�on desaibed herein on the dates s�led:
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� RougMin Inspection Required? ❑ Yes �NO Itupection Other Than Rough-In: �Ready Now � WAI CaN
You muat caA the inspeda when readyl �` Date Ready. .
I ceAify that I am 1he LICENSED CONTRACTOR ❑ COMPANY 0 OWNER and hereby request inspeciion af U�e �I wak at: