P - 76025REQUEST FOR ELECTRICAL INSPECTION �� ,
2� 0 4, ��� 5 2 � Minnesota Board of Electricity
9821 University Avenue Suite &128, Saint Paul, Minnesota 55104
���� (651)642-OBOOTTY/MRS 1-800-627-3529 www.edectricity.state.mn.us
Describe -using the back of_the ' e py'rf necessary - the arork covered by this request:
� �� � � ��� ���
GENERAL FEES Outdoor Li htin Standard @$1
SERVICES / POWER SUPPUES Traffic Sfqnal StarMard C� $5
Above 200 Am ere a$10
ALARM, COMMUNICATION, REMOTE CONTROL, SIG
CIRCUITS, CIRCURS OF LESS THAN 50 VOLTS
Each m Devi� or A pa�atus $.50
ADDITIONS TO THE GENERAL FEES
3 to 12 Units �$50 Per
Each Addfional Unft C� ;
�11 u 111 II �II II II� II I�I I� I�I II III II II) �� I�
�Q499521
ONE & NVO FAMILY DWELLINGS, EACH UNR
Includ�s the Servtce andlor Power Supply up to 500 Amper�, A�
Circufts and Two Inspei.fion Tdps Each Dwelling Unit @$80
Addfional I�s 'on T $20
Irn�stfgative Fee
Reins 'on F� $20
TOTALFEE
(minimum total fee is $20) � �
'nas naFn � msa�cron usE aar
I herebvi certiTV that I(nspeded fhe electrical insta�adon d� hereki on the dates a�ed:
FOFt UFFICE USE OtdLY
���� i� / ��
�
� � —U� �
"""'' Rou h-in In on R uired9 ❑Yes No Ins
_ O� 9 � eq pealon Other Than Rough-In: ❑ Ready Now WIA Call
�—� You must call the inspector when readyi Date Ready.
I certi�y that I am the �LICENSED COMRACTOR ❑ COMPANY ❑ OWNER and hereby request insp�tion of the electrical wark at
Job�StreetAddress �� �\i� �� C��il� �"�.�A
v� 1.� ���� �
Eiectrical UL'1(tty Addres
�enterpoint En rgy '
en re ve �
Anoka, MN 55304 ,
a�7 �9 Pa4�� �g Insmllatlon)
„ _ „ 4 4
�h���
Please Provide Two (2) Photre Numbers Including Area
�g°"°t�.. .lo� �� )
�se�Master Electricdan or Power Limi6ad 1
� Lice�e Number
Please Provide Two (2) Phone Numbers Including Area
fn�)i°�—���� )
�_,�,�,,,e .t