P - 75823REQUEST FOR ELECTRICAL INSPECTION
�� 9 9��� 2 6 � Minnesota Board of Electricity
1821 UnNersity Avenue Suite S-128, Saint Paul, Minnesota 55104
` (651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
DescribeRt+�ng the back of the white copy ff necessary - the work covered by this requ�t:
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GENERAL FEES Outdoor Lighting Standard @$1
SERVICES / POWER SUPPLIES Tra(fic Sianal Standard !n� R5
� CIRCURS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.5D
ADDI710NS TO THE GENERAL FEES
CeMer
I THIS
$50 Per Unit
Unit @ $25
Hour
Mile
�Y BE ORDERED
�I) Illu III�) (IIII �I�I I) �II II (I� (� ul �� (�r
19925262
20
ONE & TWO FAMILY DWELLINGS, EACH UNR
Inctudes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Insp�on Trips Each Dwellirtg Unit @$80
Add�donal Insoection Trios an $20
I
TOTALFEE I 7��—�
total fee is $201
that I Ns�ed the etecticat InstaOadon descrmed here6i on the dates sts�:
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INNECTED IF NOT COMPLETED WITf
POR OFFICE USf QNLY
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uau,: Rough-in I eq I
�r� nspecHon R uhed? ❑ Pto Inspection Otlrer Than Rouglrin: � Ready Naw�iM1li� Cap
~��° You must wIl the Ins
pector x�hen readyl Date Ready:
I certdy that I am the ❑ UCFJVSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby requegt inspection of the electrioal work at
Job S(te Street Address
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Township Secdon Renge Fire No. County
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I UtlIRY Eledricel UtlQty Address
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or mPe�Y � Coritredor License Numoer nnaster r�ecmcian or Power Ltrnttetl
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�ddr�s (Cor�ador Company or Owner PerformNg Instapatlon
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�d IgnaWre (C ntiactor or er Performing Ir�teUadon) Please Provide Two (2) Phorre Numbers InrJuding Are,_
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INSTRUCTIONS ON BACK OF LLOW COPY BOARD OF ELECTRICITY COPY EB-00001A-15 e.t. 2004