P - 75767REQUEST FOR ELECTRICAL INSPECTION -
1' 9 4 2" ��� � Minnesota Board of Electricity
1821 Unnrersity Avenue Suite S-128, Saint Paul, MinneSOte 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
Desaibe -usim3 the �ck of the whfte copy'rf necessary - the work covered by is requ�at:
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ALARM, COMMUNICATION, REMOTE CONTROL
CIRCURS, CIRCURS OF LESS THAN 5D VOLTS
Each S tem Device or A�s��aratus @$.50
ADDRIONS TO THE GENERAL
Each Addfional Unit
CeMer Pivot Irriaation B�m
,� � nTION MAY BE ORDERED
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ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service antUor Power 5upply up to 500 Amperes, NI
Circuits and Two Inspe�,fion Trips Each Dwelling Unit @$SO
Addi�onal Ins 'on Tri $20 �
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Irnesti ative Fee
Reins 'on F� @ $20
TOTAL F�
(minimum total fee is $20)
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I hereby ceNry that I inspeded tlte electrical InstallaUon desaibed here.in nn the dat� s�ted:
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IF NOT COMPLETED WITHIN 12 MONTHS
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�� Rough-in Inspection Required? ❑ Yes �No InspecUnn Otlier Than Rough-In: ❑ Ready Now ❑dV� Call
���1(%� You must call the inspedorwhen readyl Date Ready.
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I certify that I am the 0 LICENSED COM{RRCT01t ❑ GOMPANY ❑ O1NiVER and hereby request inspection of the electrical work at
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