P - 76090REQUEST FOR ELECTRIC L INSPECTION
�� o��� 6 O� a Minnesota Board of Electricity — J(' �$�► I
1821 University Avenue Suite &128, Saint Paui, Minnesota 55104
(651) 642-0800 TTl'/MRS 1-800-627-3529 edectricity.state.mn.us
Descnbe -using the backvf the wrhlte copy'rf ne�sary - the wwk covered by this r�uest: �- \
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Above 800
CIRCUITS OF LESS THAN 50 VOLTS
Manufactured Home Park Lots I
RecreaBonal Vehicle Park Sit�
4LLATION MAY BE ORDEREI
II�I I� III II �u II III u II� I� �I II III U III �� I�
�051681�
ONE & 1W0 FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, M
Circ.uits and Two Inspection Trips Each Dwe�ing Un� @$80
total fee is $20l � 0`2 D•�
I herebvi certiN that I im�ed fhe el�drical 6istelladnn d� herein on the dates sfat�:
F'OR OFFlCE USE ONLi
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�� Rough-In InapecUon Required? ❑ Y� �lo InspecHon Other Than Rough-In: ❑ Ready Now Call
�— r7C /� o l!� You must call the U�sp�tor when ready! Date Ready. '
I certify that I am the �I, UCENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby r�uest inspection of the el�trical work at
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Lk�nse Number Master Electridan or Pwrer Ltr
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