P - 77189[� REQUEST FOR ELECTRICAL INSPECTION
1� 1� J- 5 5 7� Minnesota Board of Electricity
1821 Ur11'versity Avenue Suite S-128, Saint Paul, Minnesota 55104
�� 3�� (651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
❑ NEW EMODEL ❑ ADDITION ❑ REPAIR Describe -using the back of the white copy'rf necessary - the work covered by this request:
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SUPPLIES
CIRCUITS OF LESS THAN 50 VOLTS
ivstem Device or Apparatus � 5.50
3 to 12 Units
Mile
I IIII II I!� II I!I II III l�'!I fl III II III II II! q� I�I
1 7 2 9 5 5 7�
Sqndard
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Grcuits and Two Inspection Trips Each Dwelling Unit @ S80
TOTAL FEE I c(�
(minimum total fee is $20) � U '�
r�xsu� w+r+scECrae us� aar
I hereby urify tl�at I inspx0ed tlie �al insfaNation described herein on tlie da4s sfaled:
3-3-�'� I
IF NOT COMPLETED WITHIN 12 MONTHS �
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�coquesz u�e: Rough�n Inspection Required? L] Yes �NO Yspepion Olher Than RougMn: ❑Ready Now VWI Call
I��, `O S You must call the inspector when ready! Date Ready.
I certiy Ihat I am the�[ICENSED CONTRACTOR ❑ COIu�ANY ❑ OWNER and hereby �equest inspection of ttie electrical work at: