P - 75629REQUEST FOR ELECTRICAL INSPECTION
2� 0 2 2�� 0 4. � Minnesota Board of Elect�icity ,
- r 1821 University Avenue Suite S-128, Saint Paui, Minnesota 55104
• (651) 642l0800 T1Y/MRS 1-800-627-3529 www.electrfcity.state.mn.us
D�caibe -usiqg the,back of the uvhite copy'rf necessary - the wq�lc cover� by this request:
4U1 to 800
I CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Unit
ONE & 1W0 FAMILY DWtLLIN��, tn�n urvi i
Includes the Service and/or Power Supply up ro 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$60
I hereby certlfY that I
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sin on tlre dates sTated:
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Date: Rough-in Inspectlon Requir�9 yµ�res ❑No Inspecdon OtherThan Rough-In: 0 Ready N �
��""�.(}(��j ( You must call the inspedor when readyt �e R�Y
I certify that i am the � LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request ins�Ction of the electrical work at
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�rK tfF vF1 LOW GOPY BOARD OF ELECTRICITY CAPY __ EB-00001A 15 8 7 2004