P - 76338� � � � � � � � , REQUEST FOR ELECTRICAL INSPECTION �
� � � Minnesota Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.edectricity.state.mra.9es�
D� -usim� thal�ack of the white copy if necessary -�k covered by this requ�t: -—�
:URS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDffIONS TO THE GENERAL
Each
I�I ulll (I�� �IIII (IIII �III Illu (IIII �W I�
�0�� 21165055
��_
Traffic
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT y.
Includes the Service andlor Pmver Suppty up to 500 Amperes, M
Cira�ts and Two Inspection Tri{� Each Dwellmg Un� Q$80
Addfional Ins 'on Tri $20
Imesdgative Fee
Rems 'on F� $20
TOTALFEE
(minimum total fee is $20)
TM9AI�APoRQLSPECTOR Y
I herebvi certlfv thal I InsDeded Ne eledriml i�adon d� herein on fhe dafes atat�:
i IF NOT COMPLETED. WITHIN 12 d
I�L,.Ii LI � 1 ��S�v�v�oo/
0 L
� ��� ����
-2?-a�
�� //� �� Rough-in InspecNon Requhed7 ❑ Yas�No Inspe�on Other Than Rarrgh-In: ❑ Ready Now�W� Cell
� �,
You must celi the inspecbor wfien readyi Date Ready.
I certify tl�at I am the LICENSED CONTRACTOR D COMPANY ❑ OWNER and hereby request irdsp�tion af the ele�rical work:at
Jo6$(� Street Cily
�` � . . %i� . i n _ . t P �s _ _ 4 � .
�����
u�
'S
� ��.-� � �`ss�°`f
(�/�
Ple�e Provide Two (2) Phorre Numbers Including Area Code
l �c ) �7.� ��1� (�°�� ) 8'�'.���i/�