P - 75791REQUEST FOR ELECTRICAL INSPECTION �`�"_
��� 2�� 4, � 2 � Minnesota Board of Electricity �
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651)642-0800TTY/MRS 1-800-627-3529 www.edectricity.state.mn.us
�� ���.�, +n� nark oflhe white�ecessary - the work covered by this r�uest: � �j i �-. � 0
f'l' �iroa,+ � �" I •.
GENERAL FEES ' Outdoor Lightin Sfandard @$1
SERVICES / POWER SUPPLIES Traffic Signal Standard @$5
0 to 400 AmDete C� $25 Suoolemental Fee na �20
iM, COMMUNICATION, REMOTE CONTROL
,URS, CIRCUITS OF LESS THAN 50 VOLTS
Each Svstem Device or Ao�ratus (�D $.50
Addrtional unit @ $25
orHeR noomowu.
CeMer
Hour
LATIOIV MAY BE ORDERED D
i iiri ii iii ii �i i� il� ii i0i ii � ii ai � i� o� i�
18204529
wer
ONE & TWO FAMILY DWEWNGS, EACH UNIT /
Includ� the Service and/or Power SuPP�Y �P ��0 Amperes, All
Circuitc and Two Inspection Trips Each Dwelling Unit @$80 6
Addfional Ins 'on Tri $20
Imestiqative Fee a —
,� TOTAL FEE '.�q
. /�' �= ' /(minimum total fee is $20) `-� v
iws F�in�croausE r
��r1�� °�c� �t,�ri ca\�c>>c.es
I here6y ceNy I Inapeded the elecMcel imiallatlon described herein on the dates e�fed:
awcx w ��
�.d� � -�
���� ��
��� .3 l�
APLETED WITHIP112 MONTHS
!=t�k UFFiCE USE O�dLY
� � � V! � � O �"� ' /
"""'' Rough-in Inspectlon Required7 �Yes ❑ No Inspecdon Other Then Rough-In: � Ready Now 0 W81 Call
� °� D� You must call the inspedor wrtten ready! Date Ready.
I certify that I am the ❑ UCENSED CONTRACTOR ❑ COMPANY,�OWNER and hereby request inspection of the electrical work at
Job S� 1� Y'r'� � 1� �'�I r ��� � 1 i\�
or
rue rvo. w
��
Please Provide Two (Z) Phorre Numbers In�duding Area Code
(6e�)�l�`� V��2. (71v3)�77'� ��
�se Number Mesber El�triclan or Power LlmRed Techni
License Number
Please Pravide Two (2) Phone fVumbers Including Area Code
` / \ /