P - 75605i REQUEST FOR ELECTRiCAL INSPECTION °'� �
� s��� �$ 4, � Minnesota Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651)642-0800TTY/MRS1-800-627-3529www.elecdricity.state.mn.us -
Describe -using the back of the wh(te copy ff necessary - the work covered by this reque.st:
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GENERAL FEES Outdoor Lighting Standard �$1
SF1tVICES / POWER SUPPUES ._ � l Traffic Sianal Standard ��5
tM, COMMUNICATION, REMOTE CONTROL
�UITS, CIRCURS OF LESS THAN 50 VOLTS
Each Svstem Device or Aooaratus C� $.50
Unit @
FEES
Includ� tha Service and/or Power Supply up to 500 Am�r�, All
Circuits and Two Inspec�ion Trips Each Dwellmg Untt @$80
Addfional Ins 'on Tri $20
Imresti ' Fee
Re on Fee $20
TOTAL FEE �
(minimum total fee is $20) �
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��' Rough-in Inspectlon Required9 ❑Yes ❑ No Inspection Other Than Rough-In: � Ready Now �Will CaA
��[ (d � You must call the inspedor when ready! Date Ready.
I certify that I am the � LICENSED CONTRACTOR ❑ COMPANY �OWNER and hereby request inspection of the electrical work at
Job Site Street Address CKY
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mawng naaress (c;ontrac[or, Company or
A ` Ig�tu�e (Contrador or
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NISTRUCTIOPI ON BACK OF YELLOIN COPY
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eI Utllfty Addr�s
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Contrador License Number Masfer Etectrictan or
Licer�se Number
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