P - 76969REQUEST FOR ELECTRICAL INSPECTION
1� V� lJ -�6 6 Minnesota Board of Electricity
. 1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104 -
� � • ' (651) 642-0800 TTYlMRS 1-800-627-3529 www.electricify.state.mn.us
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Describe -usi back of the white copy 'rf necessary - the work cove yy regue�st: /!V STi4L ►- �/V 6�4 S 1+6 - �4+�G. 3C+R
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GENERAL FEES Outdoor Liahtina Sfandard (aD 81
I SERVICES /
ALARM, COMMUNICATION, REMOTE CANTROL, SIG
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or aratus $.50
ADDITIONS TO THE GENER4L FEES
3 to 72 Units (a� $50 Per Unk
Each Additlonal Unit (c� $25
OTHER AD
LiphUn� Retrofit Cd! 525 oer F
Treffic
� 7ransfomier / Power Supply fa Signs / Outline Lighting @ S5
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 5� Amperes, All
Circuits and Two Inspection Trips Each Dwellirg Unit @ a80
Additional Insoectbn Tri�s �t t20
TOT/LL FEE / �
total fee is $20) � / �` —
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� hereby certiry tnat �:�ectea me elecaica� i�taua6on describad nerein on n�e dates slated:
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�THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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Date: Rough-in Inspection Required7 �Yes ❑ No Inspection Other Than Rough-In: � Ready Now�QWill Call
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Vou must caN the inspedor when readyl D�te Ready:
i cefiy that I am the ❑ LICENSED CONTRACTOR ❑ COMPANY $[ OWNER and herehy request inspection of the electrical woric at
Job Site SVeet Addre� ��,
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Township Section Range Fire No. CouMy
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Owne�/Oca�PeM Name Please Provide Two (2) Phone Numbers Induding Area Code
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Electrical Utilily Electrical Udkty Address
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s(CoMractor, Company a Owner Performing Installetion;
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DN BACK OF YELLOW COPY BOARD OF I
cior ucense rvumoer masaer t�ecmaan or Nower umrtea �
License Number
32
Please Provide Two (2) Phone Numbers Induding Area
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