P - 78973,
�.-683-390 �
L�]
❑ REPF
ALARM, COMMUNICATION, REMOTE CONTROI
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
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.electriciry.state.mn.us
�Describe -using the back of the white copy if necessary - the work covered by this request:
G � G- Y I � �- `� �i'7c /L d S.a �c�?/��
to 10 KVA
ONE 8 TWO FAMILY DWELLINGS, EACH UNiT
Includes the Service andlor Power Supply up to 500 Amperes, All
CircuiLs and Two Inspection Trips Each Dwelling Unit @$80
�AMiLY DWELLINGS PER UNI TOTAL FEE
to 12 Units @ g50 Per Unit (minimum total fee is $20) �, �
3Ch AddiGOnel U�it @$25 rH�s u�n F«+ir+s�cTat usE aar
I hereby ceAify that I inspeched fhe electrical insfalla6on described herein on the da0es s�d:
OTHER ADDITIONAL FEES � r v�i ��� 7�
ahtina Refrofit �$.25 oer Fizture r�����
�
Mile
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16833907
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4� �e� Roughin Inspection Required? es ❑ No Inspedion Oth� Than Rough-In: OReady Now Cell
� 0 �� O You must calt the inspector wf�en ready! Date Ready.
:rtify that I am the �u�ErySED CONTRACTOR OCOA�ANY ❑ OWNER and hereby request inspection of the eiectriral wak at�
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