P - 782321-460-743 �
O NEW ❑ REMODEL ADDITION O
�,J r'�e all'S�i,�7lZSA
�M, COMMUNICATION, REMOTE CONTROL,
:UITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENERAL F
iIFAMILY DWELLINGS (PER UNI�
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
OTHER ADDITIONAL FEES
Lighfing Rehofit @ $.25 per Fixture
Center Pivot Irtiaa6on Boom � S40
REQUEST FOR ELECTRICAL INSPECTION
Minnesota Board of Electriaty
1821 University Avenue Suite S-128, Sairrt Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
41R Describe -using e back of the white copy 'rf necessary - the work covered by this request:
�
Outdow Liohtina Standard (� $1
IIIINIIIIIiIIlilIIIIIIIIIIhII�hllla� I�
14607436
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit �$BO
TOTAL FEE I `�
(minimum total fee is $20) �r/
iH15 AREA FOR INSPECTpi USE Mv
I hereby cerUy that I inspected the electrical install�on described herein on the da0es stated:
��,
� NOT COMPLETED WITHII
� �5 �a�
'�j. ,SO
rcequesc ua[�e:` Rough�n Inspection Required? ❑ Yes CrNo �rupectip� p�her Than Ragh-In;�7Ready Now 0 Vlfill Call
/� ��J �O 3 You must call Me inspeclor when ready! Date Ready: �. �� 3
I certify that I am the ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of tlie electripl work at:
Job Site Address (Street BoX � Route ) Ci 7� �e
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0
: numoer neester r�ectnaan a
A �J �% License Number
(I�C /
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