P - 76356�}��� `� REQUEST FOR ELECTRICAL INSPECTION ✓ ��
J�� � 0�°� 1 2 � Minnesota Board of Electricity
1821 University Avenue Sufte 5128, Saint Paul, Minnesota 55104
(651) 642-OS00 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
Desaibe -using the back of the white copy ff na�ssary - the a�ork cover� by this r�u�t:
�(�c� i nn ��i r���.n o� V�D n i�-cr Qn �-- �� �=�:•
I SERVICES /
�e eoo
�UITS / FEE
0 to 200 Ai
F�
�
over
A6ove 200 Am re 10 Includes the Service andlor Power Supply up to 500 Amperes, AII
tM, COMMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Two Inspection Trips Each DwePng Unit @$80
;UITS, CIRCUITS OF LESS THAN 50 VOLTS Add'fional Ir�s 'on Tri $20
Each S em Device or A paratus (a� $.50 Invesd ative Fee
ADDITIONS TO THE GENERAL FEES Reins on Fee $20
TIFAMILY DWELLINGS PER UN TOTAL FEE /�'� �
3 to 12 Units @$50 Per unit (minimum total fee is $201 l
i Home Park Lots l
Vehicle Park Sit�s
INSTALLATION MAY BE ORDERED
I i�eded tlre etectrical i�aVaUOn desamed herein on the da0as st�d:
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�— f�� �� You must cell the inspec4or when readyl Date Ready: 3—' q-����
"I certify that I am the 0 LICENSED CONTRACTOR ❑ COMPANY �OWNER and hereby request inspection of the el�trical work at
Job Sfte Street Address �hy
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or
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master tiecmctan or
Licer�se Number
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ON BACK OF YELLOW COPV BOAR�f ()F FI Ff:TRIf:T' f:f1PV ca_rxinn� e_na e