P - 761731 9 7� 3 0 4� 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 xnvw.electricity.state.mn.us
Descn'6e -using the ba�k of the white copy'rf necessary - the work covere�i by this requ�st:
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Above 800
m
CIRCUITS OF LESS THAN 50 VOLTS
Per Unit
Trafic
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Ins{�ction Trips Each Dwelling Unit @$BO
Addfionallnspection Trips @ $20
Imestiaative Fee
TOTAL FEE -� : � �'. '
total fe� IS $20) � , � l �`
I herebY certiTY � I inspeded 6re etectrical inatallallon descn'bed herain on tlre dates s�ted: �
THIS INSTALLATION MAY BE_ORDERED DISCONNECT IF NOT COMPLETED WITHIN 12 a
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��� Rough-in InspecUon Requlred4 ❑Yes �No Inspedlon OtherThan Rough-In: �Ready Now �Will CaA
7��� �/1 You must call the Nspector when reedyl Date Ready:
I ceitify that I am the �ICENSED CONTRACTOR ❑ COMPANY .� OWNER and hereby request inspection of the electrical work at
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Confiador License Number Master Electridan or Poaer Lim(te
License Number
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Please Provide Two (2) Phorre Numbers Induding A
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