P - 761121-��?'041 �
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GENERALFEES
SERVICES / PONdER SUPPLIES
REQUEST FOR ELECTRICAL INSPECTION
Minnesota Board of Electricity
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104 -
(651) 642-OS00 TTY/MRS 1-500-627-3529 www.electrdcity.state.mn.us
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IITS, CIRCUITS OF LESS THAN 50 VOLTS
ach System Device or Apparatus @�.50
ADDITIONS TO THE GENERAL FEES
FANllLY DWELLINGS (PER UNIn
ro 12 Units @$50 Per Unit
TION AAAY BE ORDERED
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17870411
Traffic Sipnal Standard
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspecfian Trips Each Dwelling Unft @$80
AddiGonal Ins ection Tri $20
Imestigative Fee
Reins 'on Fee @ $20
TOTAL FEE �O, �iQ
(minimum total fee is $20)
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I hereby certi(y that I Inspeded the elecMcal installaGon described herein an the dates stet�i:
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WITHIN 12 MONTHS
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I U°�' Rou h-in Ins on Re uired9 ❑ Ye �] No Ins
$������ 9 pe�ti q pectionOtherThanRough-In: [�ReadyNow❑WiIlCall
You must call the inspector when ready! Date Ready:
I certify that I am the [� LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
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5�l 5 h!E 4 i H ST 114�
TomfnahiP Section Range Fire No. County
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�Y+�����U�� F���� �� � Please Provide Two (2) Phone Numbera Including Area Code
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EL ENEF:GY "
ctnr / Company Name
hIT ELECTFiIC CDfiF'OEA�IOh1
� Address Contractor, Company or Ovmer Performin Installal
04 T�Fif.ITORIAL �iOADq S���IT F
r7ced SlgrtaWre (ConUactor or Ovmer Performing Installation)
Master Elec6lcian or
License Number
9 f�h! 55114
Please Provitle Tvro (2) Phone Numbers
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