P - 78568/� REQUEST FOR ELECTRICAL INSPECTION
1� 417 ��`t �� Minnesota Board of Electricity
1821 University Avenue Suite aint Paul, Minnesota 55104
(651) 642-0800 TTY/MR -8 529 www.electricity.state.mn.us
.
❑ NEW ❑ REMODEL 0 ADDITION REPAIR' �c�i i-usin the bacl� th�hite� if r)PC,��sary - the work covered by this request:
1 a�; ii�%1 C'
CIRCUITS, CIRCUITS OF LESS THAN 50VOLTS
Each Svstem Device or ADDaratus � 8•50
3 to 12 Units �$50 Per Unit
Each Additional Unit � E25
ONE & TWO FAMILY DWELUNGS, tn�n urvi i
Includes the Service andlor Pwuer Supply up to 500 Amperes, PJI
Circuits and Two Inspection Trips Each Dwelling Unit �$ffil
TOTAL FEE
(minimum total fee is $20)
r�ns utEn Fort narECTat usE aar
I hereby certify that I inspected the elec6�c� instaYa6on desrxibed herein on the da�es sf�ed:
, - - 3�I� -a�
1 FIIS In.71 wLVa � wm m�i oc vnv�..cv ...w......�... �� .. .'� • --°-- -- . . . _ _ . . . --
«�.---- , _s� sr�:�s+::�. C;c,��..�i}yLX . . .
I �II) II III II �I� �I II� �I I�I II (II II � � � �� ( � � .
14177422 ��1���p
�O�Jr�
Rough-in Inspection Required? ❑ Yes Inspection Other Th Rw9h-In: y� ��p
Yai must call the inspector wh� ready! Date Ready: �
I certi(y that I am 1he �ICENSED CONTRACTOR 0 COWPANY ❑ OWNER ar�d here request � ction oF the electrica� wak at:
��R
� V
Mester Ele�triaan or
uoense rY,mner
�
MrBdor. Comp�y er Perfo ng Installatlon) (�6��� /_� I
�,�I�/ I�( -V�
��CK � y��yp� gpqRp OF ELEClF21CITY COPY E&00001M14 81 20D2