P - 78830REQUEST FOR ELECTRICAL INSPECTION
1�/I � 0� 1 7 7 � Minnesota Board of ElecVicity
'"r 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
� � ��j (651) 642-0800 TIY/MRS 1-800�27-3529 www.electricitystate.mn.us
❑ NEW EMODEL ❑ ADDITION ❑ REPAIR Describe -using the back of the white copy if necessary - the xrork covered by this request:
, Gv.>Sar'"1 ��SI � - `_l �S
GENERAL FEES Outdoor Li htin Stand�d S1
SERVICES I POWER SUPPLIES _ Traffic Si nal Standard $5
IMMUNICATION, REMOTE CANTROI
CIRCUITS OF LESS THAN 50 VOLTS
3 W 12 UniLt
I Illl II �I II III I I III I I III I I 11111111111II �� I ldl
14601777
ONE 8 TWO FAMILY DWtLLINC�S, tnUi Um i
Includes ihe Service andla Power Supply up to 500 Amperes, NI
Circuits and Two Inspection Trips Exh Dwelling Unit @ i80
TOTALFEE r�
(minimum total fee's S20) o��' S�
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ReQuest D�B: Rough-in Inspection Required'? ❑ Yes No inspection Other Than Rough-In: ❑Ready Now I Call
�" � 3- d3 You must call tlie inspector when ready! Date Ready. ,
I c�dfy tl�at I am tl�e �LICENSED CONTRACTOR ❑CONWANY ❑ OWNER and hereby �equest inspeciion of ihe elec4ical wak at: