P - 76082REQUEST FOR ELECTRICAL INSPECTION
� � � � � � � � � � Minnesota Board of Electricity
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-500-627-3529 www.eleclricity.state.mnves
-using the bacic of the whtte copy'rf necessary - the work covered by this request:
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' GENERAL FEES Outdaor Liahtina Standard na �7
I SERVICES /
.UITS, CIRCURS OF LESS THAN 50 VOLTS
Each Svstem Device or Aooaralus l�D $.50
Unft (a�
5 per Fodure
Boom C� $40
Trafic Sianal Standard
ONE & TWO FAMILY DWELLINGS, EACH UNR
Includas the Service and/or Power Supply up to 500 Amperes, All
Ciraiits and Two Ins�Ction Tdps Each DwelPmg Unit @$80
Additional Inspection Trips @ $20
Irn�stlaative Fee
total fee is $20) I,-./ V�
I hereby certify tliat I In� the ele�ical instelladnn described herein on fFre dates sfaf�: I
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THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
FOR OF=ICE USE ONLY
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g nspectlon Required9 ❑ Yes �lo I�pectlon Other Then Rough-In: Ready Now ❑ WIO Ca0
1 V�' ��'^Q Sp You must ca0 the i�pe�tor when readyl Date Ready: �'� V
I certify that I am the LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical wark at
Job Site Street Addr�s
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WSTRUCTIONS ON BACK OF YELLOW COPY BOARD OF ELECIRICITV COPV
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mber Master Electridan or Powar Lhnited TecFjp{qan
, Llcense Number `t � )
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� Provlde Two (2) Phorre Numbers Includln Area
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