P - 75880REQUEST FOR ELECTRICAL INSPECTION �
� � � � � � � 13 � Minnesota Board of �le 'city
1821 University Av u�,4uit S-128, Saint Paul, Minnesota 55104
� (651)642-0800 /� 00-627-3529 www.electricity.state.mn.us
Descdbe -usina the f.lAe coov if nec�ssan� - the work cover� bv this reauest: _ o
0 to
21N, COMMUNICATION, REMOTE CONTROL, SIGNALING
:UITS, CIRCUITS OF LESS THAN 50 VOLTS
Each Svstem Device or Aaoaratus (o� $.50
Boom
� L ►
r�g Standard
4fandard @;
Fe.e C� $20
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includ� the Service amilor Power Supply up to 500 Am�res, All
Circuits and Two Inspection Trips Each Dweuing Unit @$80
Addi�onal I�pedion Trips (a� $Zp
InvesBuative Fee
total fee is
I 6� the electrdal 6�tallaticn desaibed heretri on tlre datea atated: I
6� 3e-�C I
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
FOR OFFICE USE ONLY
III�IuII�OIIIIIIuIIII�IIIIIIIIII�III��I�
2 0 1 2 2 1 3 1 ��,� ������ '
Rough-fn Inspecdon RequUed? ❑Yes o Inspadion Ofher Ro g y �WfO Ca0
You must cell the Inspecbor when ready! Date Ready:
I certify that I am the�LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request ins{�tio of the electrical work at
, � �
Sectlon
t
nt Nem � �
e
Electrica�
� ��e � �C�
s(Cont tor, Co pen o�;/" 4 V lerfortrti �
� �� � i
� re�� r or Owner Perfo g I
DN BACK OF VELLOW GOPY Rn
mas�er rrecmaan or
Li�r�se Number
�
�
�