P - 76081ry` REQUEST FOR ELECTRICAL INSPECTION �'
L� 0 7 2�� 7� � Minnesota Board of Electricity
1821 University Avenue Suite 5-128, Saint Paul, Minnesote 55104
�.�, (651) 642-0800 TTY/MRS 1-800.627-3529 www.elecJricity.state.mn.us
D�cribe -� dri�the bac c of the white copy'rf necessary - the work covered by this est:
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CIRCUITS OF LESS THAN 50 VOLTS
ivstem Device or Anaaratus C� $.50
Manu(actured Home
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ONE & Nd0 FAMILY DWELLINGS, EACH UNIT
Includes the Servi� and/or Poarer Supply up to 500 Amper�s, All
Ciraiits and Tvro Inspection Trips Each DweNng Unit @$80
Add'�fonal Ins�ection Trias (a� $20
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total fee is $20) �� ' �
I hereby certlty that I irepected the eledriral fnslallatlon d� herehi on the dates �[ed:
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FOR OFFICE USE OPlLY
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I ��� Rough-in I�pectlon Required7 ❑Yes �o Inspedion OfherThan Rough-In: [gReady Now ❑WN Ca0
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You must call the Inspe�or when readyi Date Ready.
I c�rtify that I am the I�I LICENSED CONTRACTOR ❑ COMPANY 0 OWNER and hereby request inspection of the ele�trical wrork at
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dor or PeAOrtning Instelladon) Pleasa Provide Two (2) Phone Numbers Including Area Code
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