P - 76027REQUEST FOR ELECTRICAL INSPECTION `
1� 9 2 6— 6 9 4� Minnesota Board of Electricity
1821 Universily Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1�00-627-3529 www.edectricity.state.mn.us
Describe -using the beck of the whfte py if necessary - the wrork covered by this request:
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GENE FEES Outdoor LI htin Standard
SERVICES / POWER SUPRLIES � Traffic Sianal SYandard iv �5
CIRCUITS OF LESS THAN 50 VOLTS
ivstem Device or Aooaratus (�D $.50
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Manufactured
Includes the Service andlor Pouver Supply up to 500 Amperes, M
Circuits and Two Ins�on Trips Each Dwelling Unft @$80
Addfional Inspection Trips @ $20
Imestiqetive Fee
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total fee is $201 .
I inspeded tlre elec6lcal ir�staVad desmbed herein on fire dates sleted:
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THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIW 72 MONTHS
FOR OFFICE USE OPii.Y �
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I certify that I am tha
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Rough-In Inspedion Requhed7 es ❑ No Inspedion Other Than Rough-In: � Ready Now 01M1� Cap
You must cell the inspector when readyt Date Ready:
VSED CONTRACTOR ❑ COMPANY ❑ OWNER am1 hereby request inspection of the eledrical work at
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INS OM BACK OF YEILOW COPY
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