P - 75256REQUEST FOR ELECTRICAL INSPECTION
� s � � � � 4 � � � Minnesota Board of Electricity
1821 University Avenue SuRe S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 wovw.electricity.stade.mn.
Dascnbe -using the back oF the white copy if n - the work covered by this request:
� _ . � _ ,r �i cr' � 1� �
3 800
/ FEE
�IN, GOMMUNICATION, REMOTE CANTROL, SIGNALING
;URS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENERAL FEES
TIFAMILY DWEWNGS (PER UNIn
3 to 12 Un'ds CD $50 Per Unft
Home
LATION AAAY BE ORDERED 0
I(IU 11IU U IU �� II IU ��I II III II111 �� I�
Outdoor
Transformers up to
Trar�sformers over
Includes the Service and/or Power Suppty up to 5D0 Am{�res, All
Circuils and Two Inspecbon Trips Each Dwellim� Unit (� $80
Reins 'on Fes $20
TOTALFEE
(minimum total fee is $20) ��% �
ir � TM�a�nwnu�croau�ornr
C�''i�-'- t�' 7 � °-�>
i n�y �rtuym� i rn� ei� n�ue�o� a�a n�� o� mma a� �mma:
�,w ��
- � c�
IF NOT
FOR OFFICE USE ONLv
3�� ��
12 MONTHS
1820 416 4 �������� ���
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��' Rough-in Irrepectlon Required? ❑ Y� ❑ No Inspedion Other Than Rough-In: ❑ Ready Now � WIII Ca0
�'� �m V l� You must call the inspector when readyl Date Ready:
I certify that I am the 0 LICENSED CONTRACTOR ❑ COMPANY � OWNER and hereby request insp�tion of the electripl wrork at
Job 31te Street Addr�s
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Provlde Txro (Z) Phorre Numbe�s Includh�g Area Code
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LiCBr� NUrtlber
I Address (Conhactor, Company r Owner e Ins�Ilatlon)
�"E'� S�'��e l� � d'>'1N
Sigr�atu r Owner P ng Installation) Please Provide Two (2) Phone Numbeis Induding Area Cade
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�CTIONS ON BACK OF YELLOW COW . RnAR�I f1F Fl F(;TRif`ITV lY1PV �s �.�.�.... .� ... .......