P - 75873REQUEST FOR ELECTRICAL INSPECTION �' �
1� Q�$ �� 5(� 6 a Minnesota Board of Electricity
�r r'�' 1821 University Avenue SuRe S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.edectricity.state.mn.us �" "
Descri -using the back of the white copy'rf necessary - the work red by this ra�uest:
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� GENERAL FEES Outdoor Liahtina Shandard id Q1
I SERVICES / POWER
Above Z00 Ampere @$10
iM, COMMUNICATION, REMOTE COMROL, SIG
�UITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENERAL FEES
Add(tional Unit @
CeMer Pivot
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ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two InspecUon Trips Each Dwelling Unit @$80
Additional Ins 'on Tri $20
Investi ative Fee
Reins 'on Fee @ $20
TOTALFEE
(minimum total fee is $20) C� '�
TMSAREAFORW9PECi0RIqE0�RY
I hereby certi(ythat I mspected the �ec�l h�slallatlon d� herain on the dates s�ted:
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THIS INSTALLATION MAY BE ORDERED DISCONNECTED iF NOT COMPLETED WITHIN 12 M�NTHS
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° Rough-in Inspectlon Requhed9 ❑ Yes ,� No Insp�on Other Than Rough-in: ❑ Ready Now�Wi� Catl
� f( s�� You must call the inspector when readyl Date Ready:
I certify that I am the UCENSED CONTRACTOR ❑ COMPANY � OWNER and hereby request i�pection of the electrical work at
Job Site Str�t Address Cgy ^
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Township Sedion Range Ftre No. Co
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Owner/Occuparrt Name Plea� Provide Two (2 Phorre Numbers Including Area Code
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iss (c:omiactor, Compeny or Oamer F
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Iignafuw (Con tor Owmer P c
Master Electridan or Pawer
Licenae Number
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Please Provide Two (2) Phorre Numbers I
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