P - 79121�] REQUEST FOR ELECTRICAL INSPECTION
1� 1.. O O- 5 3 5�6 Minnesota Board of Electricity -
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104
�...�a�� (651)642-OSOOTTY/MRS1-800-627-3529 www.electriciry.slate.mn.us
❑ NEW E�pqDEL ❑ ADDITION O REPAIR Describe -using the back of the white copy'rf necessary - the work cove2d by this request:
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SERVICES / POWER SUPPLIES
0 to 400 Amcere (� $25
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
pecial Inspection @ $.31 per Mile
t INSTALLATION MAY BE ORDERi
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ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 50D Amperes, All
Circuits and Two InspecGon Trips Each Dwelling Unit @$60
(minimum total fee is $20) � Q�C.J �'—
THIS AREA FqE IISPECTOR USE ONLV
I hereby certiry tl�at I inspected the electrical installation described he2in on tlie dates sta6ed:
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Raques� uaie: Rough-in Inspeation Required? ❑ Yes � Iru
pection Other Than Rough-In: ❑Ready Nau VNII Call
l�- a r Q You must call the inspector when reatly! pa� �y:
I certi(y fhat I am the�ICENSED CONTRACTOR ❑COMIPANY ❑ OWNER and hereby request inspection of the electrical work at:
Nam
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e Fire .
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Poease ProviCe Two (2) Phone Number(s) Including Nea (
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�� �� V(�umber Master Electriaen or Power limited Tec
� Licanse Number
CAPY E&OOOOtA-t4 8.1.2002