P - 75969REQUEST FOR ELECTRICAL INSPECTION
2� 0 3��.�� 7 5� � Minnesota Board of Electricity
1821 University Avenue Suite 5-128, Safnt Paul, Minnesota 55104
.s-- (651) 642-OS00 TTY/MRS 1-800-627-3529 www.electricity.st e
-usir�g the back of the ite copy ff n - the avork cov by this �t:
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GENERAL FEES Outdoor Lighting Standard $1
SERVICES / POWER SUPPLIES Traific Si al Standard @$5
0 to 400 Ampere @$25 Suoplemerital Fee Ca? $20
2U0 Ampere @$10
IMMUNICATION, REMOTE CONTROL
CIRCUITS OF LESS THAN 50 VOLTS
ivstem Device or Aonaratus (D $.50
UnR @
5 per Fodure
B�m � $4(
S al Ins on �$.37 per Mile
THIS INSTALLATIOPI MAY BE ORDEREI
II�I IIUI lllu IIIII I�-I�� �I�I IIIU Illu �� I�
�0377586
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Indudes the Service and/or Power Supply up to 500 Amperes, M
Circuits and Two Inspection Trips Each Dwelling Unit @$BO
Addffional Ins 'on Tri $20
Investlgative Fee
Reins 'on Fee @ $20
TOTALFEE
(minimum total fee is $20) � -��
TMS AREA FOR P6PECf OR U� OPRY
I heraby certfy that I inspect� the electrical I�tellatlon described hereUi on the detas st�ted:
DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
F020FFiCE USE QP+! Y
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��' Rou h-in Ins on
� s/� a�� g pectl Required7 ❑ Yes ❑ No Inspectlon Other'Rmn Rough-In: Ready Now ❑1P/� CeA
You must cell the inspedor when readyl Date Ready.
I certify that I am the CENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hareby request inspe�ion of the el�trical work at
Job Site Sheet Add C �
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