P - 76031REQUEST FOR ELECTRICAL INSPECTION "'
�� 9 21 � 1 J J � 821 Un�'nrers� A en e SueRe S-�8, Saint Paul, Minnesota 551U4
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn. us
Descdbe -using the back of the whfte copy'rf necessery - the work covered by this requatit:
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� GENERAL FEES Outdoor Liahtina Standard lD $1
0 to 400 Ar
401 to 800
A�ve SOiI
)MMUNICATION, REMOTE CONTROL, SIGNALING
CIRCURS OF LESS THAN 50 VOLTS
iystem Device or Apparatus @ $.50
ADDITIONS TO THE GENERAL FEES
3 to 12 Units
Each Addfioi
Sitas
Transformers over 10 KVA $ 20
Transformer / Power Su I for Si ns / OWine ' htin $5
ONE & TWO FAMILY DWELLINGS, EACH UNR
Inciudes the Service artd/or Power Supply up to 500 Amper�s, Au
Circuits and Two Ins�tion Trips Each DweUing Unit @$BO
Additianal In 'on Tri $20
Investigative Fee
Rein 'on Fee $20
TOTAL FEE �
(minimum total fee is $20) ��d
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I hereby ceNfythffi I in,spec0ed the electrfml f�taVatlon de�d herefn on the dates s�ted:
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1LLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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g pedion RequiraiT �Yes ❑ No Inspectlon Other Than Rnugh-In: � Ready Now OWill Call
�/��/� �B You must call the inspector when readyl Date Ready:
I certify that I am the ,� LICENSED CONTRACTOR � GOMPANY ❑ OWNER �d hereby requ�t inspection of the electricai work at
Job Site Street Address �Ky I
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Pleasa Provide Two (2) Pharre
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Conhador License Nwnber Master Elactrlcian or
Lice� Num6er
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ar Owner Performing InsffiIlaBon)
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�mer Performing Installatinn P�ease Provide Two (2) Phorre Number.
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