P - 76256. [�EQI�EST FOR ELECTRICAL INSPECTION
� � � �� � � � � � Minnesota Board of Electricity
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104
. (651) 642-08001"fY/MRS 1-800-627-3529 www.electricity.state.mn.vs
D�sc�ibe -using the back of the white copy If nec�csaryr - the work covered by this requ�t: /�
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SUPPLIES
ALARM, COMMUNICATION, REMOTE CANTROI
CIRCURS, CIRCURS OF LESS THAN 50 VOLTS
Each Addfional Unit @ $25
OTHER ADDffIONAL FEES
Lis�s hhNm Retroffi (a� $25 oer FixWre
ALLATION MAY BE ORDERE
�II IIIIIIIW I�III��II IIIII IIIII IIIII�� I�
20959789
Transformer / Power Su I for Sf ns / Outime Li htin $5
ONE & 1W0 FAMILY DWELLINGS, EACH UNIT
Includes the Servirs andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspeclion Trips Each Dmelling Unit @$60
Addibonal Ir�s on Tri $20
Invastl ative Fee
Reins 'on fee @ $20
TOTALFEE �
(minimum total fee is $20)
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I hereby ceAKy fhat I trispeded tlre elecMcal i�a0adon d�ai�d herehi on 6re detes s�Ded:
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CONNECTED IF NOT COMPLETED WITHIN 12 MONTHS ��_�(
FOR 6FFICE USE ONLY �y 2JA. f+G'/
�C� MAR 3 0 2007 �C�� -
�� I Reugh-In Inspecdon Required? g�Yes ❑ No I I
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�/�� � You must ce0 the i�pedor vrhdn readyl Date Ready.
I certify that I am the UCENSED CONTRACTOR ❑ COMPANY � OWNER and hereby request insp�tion of the electric�l work at
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