P - 76017REQUEST FOR ELECTRICAL INSPECTION
� 1' � 2 0� 4� 7 � Minnesota Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-OS00 TTYlMRS 1-800-627-3529 www.edectricity.state.mn.us
Describe -using ths l�ck a�!",e white copy'rf necessary - the work covered by this reque.st:
A�ve 800
CIRCUITS / FEE
;URS, CIRCURS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENERAL I
TIFAMILY DWELLINGS (PER UNI�
3 to 12 Units @$50 Per Unit
Lots
LLATION AAAY BE ORDERED I
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182�4172
Traffic Sianal Standard
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includ�s the Service and/or Power Supply up to 500 Am�res, A�
Circuits and Two Inspection Trips Each DweUfr�g Unit @$80
Addfional Irrsaection Trias (�d $20
total fee is
I hereby cerdry thffi I Nspeded the elec�ical Inslalladon desaibed herein on the dates sfeted: I
�ok oFFicE usE ara�v
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12 MOIYTHS
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"�'a: Rau h-in Ins ��p
g pectlon Requtred9 Yea • No Inspedion Other Than Rough-In: � Ready N Cell
�° ��� You must call the inspector when readyl Date Ready.
I certify that I am the � UCENSED COMRACTOR ❑ COMPANY ❑ OWNER and hereby request ins�ction of the electrical work at
Job Site Shreet Address C(�y
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(2) Phorte Numbers Induding Area Code
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