P - 78974REQUEST FOR ELECTRICAL INSPECTION
1^ 6 9 0-12 9❑0 Minnesota Board of Electricity -
* 1821 University Avenue Suite S-128, Saint Paul. Minnesota 55104
po 18753 (651)642-0800TTY/MRS1-800�27-3529www•electricity.state.mn.us
rk red b th' uest
❑ NEW 4[REMODEL ❑ ADDITION 0 REPAIR Describe -usmg the back of fhe whde copy rf necessary - the wo cove y is req
Wire appliances, install_GFCI receptacle reconnect electric i
o ro aoo
ao� ta a
� 0 to 200 Am e $5 ONE & TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am re $10 Includes ihe Service andlor Power Supply up to 500 Amperes, All
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING Grcuits and Txro inspection Trips Each Dvaelling Unit @$BO
CIRCUITS. CIRCUITS OF LESS THAN 50 VOLTS Additional Ins tion Tri $20
to
S50 Per Unit (minimum total fee is $20)
TH45 ARE� fq21NSPECTpi l6E
U�it �$25 I hereby certifY Ihat I inspeched Me efectrical instalW600 d�cribed herein on tlie datrs sta6xd:
OTHERADDITIONAL FEES rf �d �— �e2 00 �
. � e nc .,.., r:..�...e P-
�i�� �{ III �I {I I �I {II {{ III II II� I{ III �{ III II I!I ( IIII
169�1290
_ t L -( b��Gy
are
�"Z—/7 a
a -�9 \/� �i�..Y
��
�U�" _� „ �p�,��
Reyue� v�e: Rqighin Inspection Required7 $] Yes ❑ No Inspectlon Ofh� Th� RougMn: OReady Now�VVil Call
10 /25 /04 Vou must call the inspector when ready! n� �y. _
I certify tliat I am the LFUCENSED CONTRACTOR ❑ COIuPANY ❑ OWNER and hereby roquest inspec6on of the electrical work at:
1NSTRUC710N8 ON BACK OF YELLOW COpl/ BpARp OF E�gC7ptG7y (qpy EB•00001M74 8.7. 2002