P - 760991 7 8 7 0 5 3�6 REQUEST FOR ELECTRICAL INSPECTION
� � Minnesota Board of Electricity � i
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricify.state.mn.us
Describe -usir�g the back of tl�e whfte copy if n�� �na �� ��,y �,���t: � SW T T C H
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GRCUITS OF LESS THAN 50 VOLTS
iys�m Davice or Apparatus @ $.50
� ADDITIONS TO THE GENERAL FEES
Home Park
Traffic
Fee
Includes the Seroice and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additional Ins 'on Tri $20
Investlgative Fee
Reinspection Fee $20
TOTAL FEE �^�,fje 5a
(minimum total fee is $20)
THISAREAFOR N'$PECTOR USE ONLV
I hereby certify that I inspected the electrical instelladon d�cribed herein un the dates a�ted:
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N1ISTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHII
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I"�" Rough-in Inspection Required9 ❑ Ye� �] No Inspection Other Than Rough-In: [�Ready Now ❑ Will Call
�/14/46
Yau must call the inspector when readyl Date Ready:
I c�rtdy that I am the C�] LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
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Conhactar / Campany Name
HUhlT ELECif,IC COF+F'ORA7TOh!
Maiti�q Address ConVac[or, Company or Owner Performii
�.,04 TE�f;F�ITOF�IAL R�]ADq S�
or
Utility Address
I r�hIQKA
Please Provide Two (2) Phone Numbers
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Master Electrlcian or Power Limtted
License Number
9 1-Ili ��11`7
Please Provide Two (2) Phone Numbers
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