P - 76069REQUEST FOR ELECTRICAL INSPECTION � '
1� 9 J�� 9 2 3� Minnesota Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.zrs
D�cribe -us+� a the back of the uvhite copy if necessary - the work covered by this request: /�
<., ''�" G*1G% �I/1 �� /Y 1�.AJ If�.� �}� yrl IfiR _�.few Fh.
Above 800 Am �ere $75
CIRCUITS / FEEDERS
0 to Z00 Am ere (a1$5
Above 200 Am re $10
ALARM, COMMUNICATION, REMOTE CONTROL, SIG'.
CIRCURS, CIRCUITS OF LESS THAN 50 VOLTS
Each m Device or Ap ratus @$.50
ADDITIONS TO THE GENERAL FEES
3 to 12 Units @$50 Per Unit
Each Addih'onal Unit @ $25
OTHER AD
Liahtina Retrafit an $25 �r F
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BE ORDERED
lul II III II � I) I� (� I�� II � II lu II III �� I�
L952923°'
Standard
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Cirarits and Two InspecUon Trips Each Dwelling Unit @$80
Addfional Inspection Trips @ $20
Investiaative Fee
total fee is $20) ��� � �
I herebY �erMY lhat I f�pected the electricai instsllatlon desiaihed herein on the dates stated: I
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12 MONTHS
^r� :a ricE us� c:�td��.
D�( � �l ��i
uaro: ROU h-in Ifis
g paction Required? Yes No Inspectlon Other Than Rough-in: ❑ Ready Now 0 Wi0 CaII
1�1 � V�% You must call the inspector when readyl Date Ready.
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I certify that I am the LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the efectrical work at
JobSite$tregxAddress —„j�- � C�ry ���
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Township Sectlon Rartge Fire No. County
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�Bfii��Pe�t Name _ Please Provlde Taro (21 Phone Numhers Includirro Aree Ceda
Ucense Plumber
��� r or uwmer rertorm� i iation)
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6N 80.CK OF YELLOW COPY BOARD OF EIECTRICITV COPV
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s Induding Area Code
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