P - 77055REQUEST FOR ELECTRICAL INSPECTION
1�� � L, � Q� Q � Minnesota Board of Electricity .�/�"��.Q�/�� �- � ��
�2 � �� 1821 University Avenue Suite S-128, Saint �aul, Tvlmnesota 55
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(651) 642-0800 TTY/MRS 1-800-627-3529 www.electriciry.state.mn.us
Describe -using the back of the whfte copy'rf necessary - the work covered by this request:
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GENE FEES Outdoor Lightin Standard $1
SERVICES / POWER SUPPLIES Traffic Signal Standard $5
0 to 400 Amcere an $25 Suuolemental Fee (�il $20
ALARM, COMMUNICATION, REMOTE CANTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or aratus @$.50
ADDITIONS TO THE GENERAL FEES
Center Pivot IrrigaGoo Boom �a
Manufactured Home Park Lots
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additional Ins ion Tri s $20
Investigative Fee
Reinspection Fee $20
TOTALFEE r^�
(minimum total fee is $20) p� .�j`!
THIS AREA FOR WSPECTOR USE ONLY
I hereby certi(y Nat I inspected the electrical installation described herein on the dales stated:
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12
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L 9 2 6 9 2 9 9
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� �aie: Rou h-in Ins ction Re uired?
g pe q Yes o Inspection Other Than Rough-In: ❑ Ready No ill Call
`���, \� You must call the inspector when ready! Date Ready:
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I certify that I am the �ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the elecVical work at
Job Site Street Address City
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IOwner/Occupant Name
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:'�:�lf:e Elec�ric Services
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Number
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Master Electrician or Power
License Number