P - 783631-4��-296 �
�.
❑ NkW ❑ REMODEL ❑ ADDITION �
GENERAL
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
to 12 Units �
ach Additional
I I� II I�I �I �II I� (II (� III II II� II II) I �I
IIII Illn II�
.L4262968
REQUEST FOR ELECTRICAL INSPECTION
Minnesota Board of Electricity
1821 University Avenue Suite S-128, SaiM Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800�27-3529 www.electricity.state.mn.us
� Describe -usi�g the back of the white copy 'rf necessary - the work covered by this request:
�U iG�
Outdoor Liphtinq Standard � S1 r ,_. . c
Traffic
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit �$BO
AddiGonal Inspection Trips � $20
I Investi�ative Fee �—
(minimum total fee s $20) � oCJ- � �
THISM ORINSPECTp2U5E0KY
I hereby cer6ry that I inspected the electrica 'n on the da0es sla6ed:
Rd1GH IN � ��
FIN4 M15PECTION /�+ �� �
_ ( �C � Z-.�.-r}oJ
�oiea�roorfn � w� .
CTED IF NOT COMPLETED WITHIN 12 MONTHS
�-. . :.' d . . _ ''4F..'.
,� �f Q� 3
_ �3t�.50
Request Date: Rough-in Inspec[ion Required? ❑ Yes No Inspection Other Than Rough-In: ❑Ready Now � Wdl Call
� 3 ��1 You musl call the inspector when ready! pete Readr
I certiiy that I am the ❑ LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of Uie electrical xrork at:
ma ��cw .una vn ew�:�c �r �t�tvw cOPT � BOARD OF ELECTRICITV CAPV EB-00001M74 8.1. 2002