P - 76105REQUEST FOR ELECTRICAL INSPECTION
1� 7 8 7� O 8 6 � Minnesota Board of Electricity '• i
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
D�C�+be -usinglt+e back of the white copy'rf n e y i t
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GENERAL FEES Outdoor Lighting Standard @$1
$ERVICES I POWER SUPPLIES Tra�c Sipnal Standard (� $5
� CIRCURS, GRCUITS OF LESS THAN 50 VOLTS
Unft
Hour
Mile
FEES
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17870866
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Inctudes the Service andlor Power Supply up to 500 Amperes, All
Circuiis and Two Inspection Trips Each Dwelling Unft @$80
Additional Inspectlon Trips @ $20
Invesbpative Fee
total fee is
I hereby certiy that I inspected the elecMcel installadon described herein on the deGes sta�: I
DISCONNECTED IF NOT
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12 MONTHS
��; ��' �� Rough-in Inspecfion Required? ❑ Ye� �] No Inspecdon Other Than Rough-In: [�Ready Now 0 Will Call
You must call the inspector when ready! Date Ready:
I cBr�fy that I am �he LI LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
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Contractar / Compan Name
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:onvactor ucense nlumber Master Electricien or Power Limited Techn6
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Please Provide Two (2) Phone Numbers Including Area Code
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